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DISEASES OF CHILDREN 



MODERN CLINICAL MEDICINE 



DISEASES OF CHILDREN 



EDITED BY 

ABRAHAM JACOBI, M.D., LL.D. 
u 

MEMBER AMERICAN MEDICAL ASSOCIATION, AMERICAN PEDIATRIC SOCIETY, ASSOCIATION OF AMERICAN 
PHYSICIANS, AMERICAN CLIMATOLOGIC *L ASSOCIATION, CONGRESS OF AMERICAN PHYSICIANS 
AND SURGEONS, NEW YORK ACADEMY OF MEDICINE, NEW YOHK PATHOLOGICAL SOCI- 
ETY, NEW YORK OBSTETRICAL SOCIETY ; CONSULTING PHYSICIAN MT. SINAI, 
BELLEVUE. GERMAN. BABTES\ WOMEN'S INFIRMARY, ORTHOPEDIC, 
MINTURN, AND HACKENSACK HOSPITALS, ETC. 



AN AUTHORIZED TRANSLATION FROM "DIE DEUTSCHE KLINIK 
UNDER THE GERJERAL EDITORIAL SUPERVISION OF 

JULIUS L. SALINGER, M.D. 



WITH THIRTY-FOUR ILLUSTRATIONS IN THE TEXT 




NEW YORK AND LONDON 

D. APPLETON AND COMPANY 

1910 



4. 



<"*< 



Copyright, 1909, by 
D. APPLETON AND COMPANY 



PRINTED AT THE APPEETON TRESS 
NEW YORK, U. S. A. 



©CI.A2513 79 



INTRODUCTION 



Henoch has thought that pediatrics should constitute the culmination of 
the student's work in medicine. Man} r diseases, although deviating in essen- 
tial points, have great resemblance to the adult types. The student is there- 
fore familiar with much, and only the special infantile diseases require par- 
ticular investigation. This work consists of a series of monographs arranged 
so as to form a systematic treatise. The affections which do not differ from 
the adult type are here omitted; they will be found under their respective 
headings in the other volumes. 

In the translation an attempt has been made to adhere as closely as 
possible to the style and phraseology of the German authors (a difficult task 
in many of these classic chapters). It is hoped that the book will fill a need 
and occupy the same place in English that it has acquired in the original. 

Julius L. Salixger. 
1919 Spruce Street, Philadelphia. 



EDITOR'S PREFACE 

American" pediatric literature has no lack of text-books. Enterprising 
publishers and benevolent or altruistic teachers have vied with each other 
in filling actual or alleged wants. They are not all without merits — on 
the contrary, some would confer honor on the literature of any country. 
Personal, and national, not infrequently international, experience and re- 
search are well represented in a few of them which are duly popular. 
They exhibit a full knowledge of European literature; and take pains in 
quoting from them though foreign statements or scientific results coincide 
with, or be in no way superior, to our own. By so doing our writers exhibit 
to a high degree both the honorable modesty and cosmopolitan erudition, 
which are characteristic of a host of American medical productions. In- 
deed I know in no country of any medical literature which combines to 
the same extent as ours practical tendencies with the persistent endeavors 
to fulfill the demands of scientific justice. That is why, without any carp- 
ing criticism, I dare say that Germany is rather inferior in the appreciation 
of foreign achievements, though the decades of German medical hegemony, 
following the era of French predominance, have passed by to make room 
for modern, universal and co-operative activity. 

The few German magazines published to gather from all over the world 
the titles of all sorts of medical output are (with almost no exception but 
the Centralblatter) storehouses which accumulate but do not digest. That is 
why American work is but little known in Europe, and why even the excellent 
German book I beg to introduce to my American colleagues, does not show 
the intimate knowledge of American pediatrics which has made wondrous 
strides during the last half century. If therein lies a shortcoming, it is not 
we but the German readers of the original who suffer from it. We do not 
look for American references in foreign books, but for the best their 
authors may be able to present to us — both as far as personal experience and 
research are concerned — and for the teaching of their best men and institu- 
tions. That is what is represented in the volume I herewith offer to the Ameri- 
can profession. 

When undertaking to edit this volume I was prepared to criticize, to 
reject, and to add. I have been, however, agreeably disappointed. Almost 
every one of the authors contributing to it is well known on this side of the 
Atlantic. They have all tried to furnish the best they had to give and have 
succeeded. If I were to select any one of the essays before us — a difficult 



Viii EDITOR'S PREFACE 

task — I might perhaps point to C. Keller's complete, but concise, chapters 
on the diseases of the new born. Jt is difficult to imagine anything fuller, 
briefer and withal more lucid than his discussions, for instance, of jaundice, 
pemphigus, melena, or Buhl's, and Winckel's diseases; or of the treatment 
of the navel, or of bathing. Still, it almost looks invidious to select any of 
the topics contained in this volume for special commendation. 

I may be permitted to make a statement which has been suggested to 
me by the appearance during the last decade or two, of many of the col- 
lective volumes, and big cyclopaedias, the works of many authors. With the 
initiative of the publishers I have no concern, nor with their — under our 
commercial and social conditions — natural tendency to preempt or to share in, 
the profits of the market. On the part of the contributors the wish to teach 
additional classes of readers makes them prone to repeat what they have said 
in previous text-books or monographs. That seems to be natural. Others may 
desire to appear in good company; that is a pardonable ambition. But there 
are those who prefer a clinical book which is written by one man who has 
had ample time and opportunity to gather experience, and a broad and deep 
enough mind to elaborate it. To that class of critical readers I belong myself. 
Still, in the case of the book I here present to the American profession, I feel 
justified in making an exception. The articles contained in it are all written 
by masters of national or international renown, are evidently weighed with care 
and circumspection guided by learning, convey everything that is worth while 
possessing, are complete but brief, brief but lucid, lucid and in part eloquent, 
and easy reading. No extensive editing could have enhanced their value. As, 
moreover, the admirable translation by Dr. J. L. Salinger has provided a book 
at least as readable as the original, I recommend it to the attention of the pro- 
fessional public as a worthy and valuable addition to their libraries. 

A. Jacobi. 

19 East 47th Street, New York. 



LIST OF CONTRIBUTIONS 



Diseases of the New-born in the First Days of Life. By C. Keller, Berlin. 

The Feeding of Children. By Ad. Czerny, Breslau. 

The Most Common Infections of the Oral Mucous Membrane in Children. 
By A. Monti, Vienna. 

Acute Digestive Disturbances of Infancy. By Th. Escherich, Graz. 

Chronic Digestive Disturbances of Infancy. By B. Bendix, Berlin. 

Infantile Scurvy (Barlow's Disease). By H. Neumann, Berlin. 

Rickets (Rachitis). By J. Zappert, Vienna. 

Infantile Scrofulosis and Tuberculosis. By 0. Soltmann, Leipsic. 

Hereditary Syphilis. By H. Finkelstein, Berlin. 

Speech Disturbances of Childhood. By H. Gutzmann, Berlin. 

Functional Nervous Diseases of Infancy. By H. Neumann, Berlin. 

Convulsions in Children. By K. Hochsinger, Vienna. 

Diseases of the Nose and Pharynx Peculiar to Infancy (Excluding Tonsil- 
litis). By J. Zappert, Vienna. 

Meningitis of Infancy, and Hydrocephalus. By 0. Kohts, Strasburg. 

Infantile Spinal and Cerebral Paralyses. By A. Hoffa, Wiirzburg. 

Chorea Minor. By B. Bendix, Berlin. 

Pneumonia of Children and its Treatment. By E. Henoch, Dresden. 

Rbtheln, Rubella, German Measles. By Ch. Baumler, Freiburg. 

Measles, Morbilli, Rubeola. By 0. Heubner, Berlin. 

Scarlet Fever, Scarlatina. By 0. Heubner, Berlin. 

Diphtheria and Diphtheritic Croup. By A. Baginsky, Berlin. 

Epidemic Parotitis, Mumps. By H. Falkenheim, Konigsberg. 

Pertussis, Whooping-cough, Tussis convulsiva. By A. Baginsky, Berlin. 



CONTENTS 



PAGE 

Diseases of the New-born in the First Days of Life ...... 1 

Defective and Pathologic Development 1 

Infectious Diseases 16 

Asphyxia of the New-born .22 

Treatment 26 

Trauma during Birth 34 

Diseases of the Umbilicus 62 

Other Sources of Septic General Infection 83 

Diseases of the Eyes 85 

Gonorrheal Inflammation 85 

Other Pathogenic Microorganisms 92 

Local Diseases 93 

Constitutional Diseases 96 

Icterus Neonatorum 96 

Pemphigus Neonatorum 103 

Dermatitis Exfoliativa . .108 

Sclerema Neonatorum . 109 

Edematous Infiltration Ill 

Melaena Neonatorum. . . . • .112 

Buhl's Disease 118 

Winckel's Disease 120 

The Feeding of Children 122 

The Most Common Infections of the Oral Mucous Membrane in Children . 138 
Changes of the Oral Mucous Membrane due to Saprophytic Microbes . . .138 

Bacillus maximus buccalis 139 

Iodococcus buccalis 139 

Mould Fungi 139 

Catarrhal Stomatitis 139 

Infections due to Pathogenic Bacteria 141 

Oidium albicans - 141 

Stomatitis gonorrhoica 143 

Staphylococci and Streptococci 144 

Stomatitis aphthosa 145 

Bednar's Aphthae 147 

Bacteria of Decomposition 148 

Stomatitis ulcerosa 148 

Prophylaxis and Treatment 149 

Acute Digestive Disturbances of Infancy 153 

History . 153 

Physiological Aspects 156 

Etiology 158 

xi 



xii CONTENTS 

PAGE 

Symptoms 167 

Treatment 168 

Prophylaxis "... 173 

Chronic Digestive Disturbances of Infancy 176 

Chronic Dyspepsia of Breast-fed Children 177 

Atrophy of Breast-fed Children ISO 

Over-feeding or Ilypernutrition 181 

Constriction of the Pylorus, Pyloric Stenosis, Spasm of the Pylorus . . 183 

Chronic Constipation 191 

Hirschprung's Disease 192 

Erosions and fissures 11)3 

Treatment of Chronic Constipation 193 

Chronic Digestive Disturbances of Bottle-fed Infants 196 

Simple Chronic Intestinal Disturbances of Artificially-fed Infants . . . 196 

Atrophy ' . . . ' 198 

Treatment of Chronic Digestive Disturbances 209 

Infantile Scurvy (Barlow's Disease) 217 

Symptoms 218 

Pathology 221 

Etiology 223 

Diagnosis 230 

Treatment 232 

Rickets (Rachitis) 236 

I. Introduction. History 236 

II. Distribution, Frequency, Influence of Season 238 

I. Distribution 238 

II. Frequency 239 

III. Season 240 

III. Age of Onset. Congenital Rickets 241 

IV. Heredity 244 

V. Views regarding the Etiology of Rachitis , . 245 

VI. Symptomatology and Diagnosis 250 

VII. Differential Diagnosis 268 

VIII. Prognosis 270 

IX. Pathologic Anatomy 271 

X. Treatment 275 

Infantile Scrofulosis and Tuberculosis 285 

Relation of Scrofulosis to Tuberculosis 285 

Scrofulosis , 290 

Tuberculosis 293 

Prophylaxis and Treatment 304 

Hereditably Syphilis 308 

I. Fetal Syphilis 309 

II. Syphilis of Nurslings 313 

A. Syphilis of the Skin and Mucous Membranes of the First Eruptive Period 313 

B. Syphilis of the Bones and Internal Organs in the First Period of Eruption 316 

C. Relapse 323 

D. Toxic and Parasyphilitic Symptoms ........ 324 

E. Mixed Infection ... 326 

F. Diagnosis " 327 

G. Prognosis . 328 



CONTENTS xiii 

PAGE 

III. Late Symptoms of Hereditary Syphilis (Lues Tarda) 329 

H. Treatment - 331 

Speech Disturbances of Childhood 337 

Functional Nervous Diseases of Infancy 347 

Conditions of Irritable Weakness . 348 

Convulsions 348 

Nodding Spasm 349 

Neurasthenia 352 

Night Terrors 353 

The Tics 353 

Onanism 355 

Vertigo 357 

Headache and Migraine 357 

Nervous Headache 358 

Gastric Colic 359 

Local Asphyxia 359 

Bronchial Asthma 359 

Enuresis 360 

Hysteria 362 

Head's Zones 364 

Treatment of Neurasthenia and Hysteria 367 

Prognosis 375 

Organic Affections 375 

Chorea 375 

Graves' Disease 376 

Epilepsy 377 

Convulsions of Children 382 

I. General Etiology and Pathogenesis . . 384 

II. Varieties of Infantile Convulsions • . . 399 

I. Occasional Convulsions of Children 399 

A. Simple Clonic Spasms or Convulsions 400 

B. Myotonia of the New-born and Young Infants 409 

II. Hyperirritability Convulsions of Infancy 416 

A. Respiratory Spasms of Children 419 

B. Eclampsia of Childhood 421 

C. Tetany of Children 423 

D. Spasm of the Head and Eyes in Children: Spasmus Nutans and Nys- 

tagmus 435 

III. Etiology of Hyperirritability Spasms 437 

III. Diagnosis 445 

IV. Prognosis 449 

V. Treatment 450 

VI. Supplement: Pathologic Anatomy 453 

Diseases of the Nose and Pharynx Peculiar to Infancy (Excluding Tonsil- 
litis) 456 

Diseases of the Nose 456 

Acute Rhinitis (Coryza) 457 

Scrofula of the Nose 467 

Hereditary Syphilis of the Nose 469 

Foreign Bodies in the Nose 473 

Bleeding from the Nose (Epistaxis) .,„,--,.. 474 



xiv CONTENTS 

PAGE 

Diseases of the Nasopharynx 478 

Acute Inflammation of the Nasopharynx; Pfeiffer's Glandular Fever . 479 

Adenoid Vegetations in the Nasopharynx 486 

Diseases of the Pharynx 500 

Acute Lymphadenitis Retropharyngeal 500 

Retropharyngeal Abscess 502 

Meningitis of Infancy, and Hydrocephalus . 508 

Simple Meningitis 508 

Serous Meningitis 510 

Cerebrospinal Meningitis 513 

Tuberculous Meningitis 514 

Hydrocephalus 530 

Infantile Spinal and Cerebral Paralyses 539 

Infantile Spinal Paralysis 539 

Infantile Cerebral Paralysis 553 

Little's Disease; Congenital Spastic Rigidity 553 

Cases of General Spasticity 558 

Athedosis 558 

Cerebral Hemiplegia 558 

Differential Diagnosis 559 

Prognosis 560 

Treatment 560 

Chorea Minor 570 

Symptoms 571 

Course of the Disease 576 

Diagnosis 577 

Pathologic Anatomy 577 

Etiology 579 

Pathogenesis 584 

Prognosis 584 

Treatment 585 

Pneumonia of Children and Its Treatment 589 

Pathological Anatomy 590 

Clinical Picture 592 

Primary Pneumonia 592 

Broncho-pneumonia 593 

Course of the Disease 594 

Prognosis 598 

Course 600 

Prophylaxis and Treatment 604 

Rotheln, Rubella, German Measles 612 

The Fourth Disease 613 

Measles, Morbilli, Rubeola 624 

Pathological Anatomy 627 

Clinical Picture of Measles 628 

Deviations from the Normal Course 635 

Combinations of Measles with other Specific Acute or Chronic Infectious Dis- 
eases 654 

Diagnosis 658 

Prognosis 660 

Treatment 662 



CONTENTS XV 

PAGE 

Scarlet Fever, Scarlatina 670 

Etiology 670 

Pathology 676 

Symptoms 679 

Variations from the Common Type 685 

Scarlatinal Rheumatism 695 

Scarlatinal Nephritis 700 

Puerperal Scarlatina . . 715 

Diagnosis 715 

Prognosis 717 

Prophylaxis and Treatment 719 

Diphtheria and Diphtheritic Croup 731 

Prognosis 752 

Diagnosis 752 

Therapy 754 

Epidemic Parotitis, Mumps 763 

History and Etiology 763 

Pathology 766 

Symptoms 766 

Course and Termination . . • 769 

Prognosis 771 

Diagnosis 772 

Therapy 772 

Pertussis, Whooping-cough, Tussis-convulsiva 774 

General Clinical Picture 774 

Pathogenesis and Etiology 775 

Individual Symptoms and Course 778 

Complications and Sequels 780 

Mixed Infections 785 

Prognosis 786 

Diagnosis 786 

Prophylaxis and Therapy 787 

INDEX OF AUTHORS 791 

INDEX OF SUBJECTS 803 



LIST OF ILLUSTRATIONS 



figure PAGE 

1. — Characteristic curve of atrophy in breast-fed child 180 

2. — Chart of weight in hypernutrition . . . .182 

3. — Chart of weight in spasm of pylorus 185 

4. — Chart of weight in atrophy . . . ■ . . 201 

5. — Chart of weight in atrophy 201 

6. — Chart of weight in atrophy . • 202 

7. — Chart of weight in atrophy 203 

8. — Chart of weight in atrophy 204 

9, 10. — Chart of weight in atrophy 205 

11. — Myotonia spastica perstans 415 

12. — Same case three months later 415 

13.— Little's disease 554 

14. — Same case; posterior aspect 555 

15. — Cerebral hemiplegia 559 

16.— Splint for infantile paralysis 566 

17. — Combined paralysis apparatus 567 

18, 19. — Braces for treatment of athetosis 568 

20. — Temperature chart in measles 630 

21. — Temperature chart in measles 631 

22. — Temperature chart in measles 636 

23. — Temperature chart in malignant measles 640 

24. — Temperature chart in malignant measles, showing pulmonary complications . 668 
25.— Mortality of scarlet fever from 1821 to 1900 . . . . " . . . .671 

26, 27. — Temperature charts in simple uncomplicated scarlatina 683 

28. — Temperature chart of pest-like form of scarlatina with buboes .... 688 

29. — Initial rise of temperature in four cases of scarlatina 689 

30. — Temperature chart in complicated scarlatina 693 

31. — Temperature chart of scarlatina simulating enteric fever 699 

32. — Microscopic section of kidney in scarlatinal nephritis 703 

33. — Pure culture of diphtheria bacilli 753 

34. — Preparation from tonsillar membrane 754 

xvii 



DISEASES OF THE NEW-BORN IN THE FIRST 

DAYS OF LIFE 

By C. KELLER, Berlin 

The pathology of the first stage of life, in its present extent, is a de- 
velopment largely of the nineteenth century and principally of the latter 
half. In this the pathologico-anatomical and embryologic investigations 
have had no less part than physiology and, in the last few decades, also 
bacteriology. Improvement in the method of investigation has furnished 
scientific results in each realm which have been of value also in the path- 
ology of the new-born in that they have stimulated further research. Thus, 
from various points the material has been supplied with which a structure 
has been erected which, in regard to systematic arrangement, reveals a de- 
cided advance since the beginning of the nineteenth century. It is true that 
this structure is still remote from completion: Many spaces and passages 
lack the necessary illumination. But, thanks to the successful activity of 
many distinguished authors in the past century, we may be proud of the total 
result. 

DEFECTIVE AND PATHOLOGIC DEVELOPMENT 

In the pathologic studies of the new-born those disturbances should first 
be considered which depend upon a defective or pathologic development. 
Here the central nervous system appears to be most commonly involved. 
That anencephalus or hemic ephalus — a complete or high-graded structural 
defect of the brain and spinal cord — renders an extrauterine or substantive 
existence impossible is obvious. The most important clinical evidence which 
characterizes such conditions, the absence of a cover to the skull (acrania), 
makes these forms readily recognizable. Hydrocephalus usually reaches 
such a degree intrauterine that perforation of the head, therefore death of 
the fetus, is necessary to render the labor less serious to the mother. Ex- 
ceptionally there are cases of less grade that permit the birth of a live infant 
either spontaneously or with the aid of instruments. Such cases show but 
a moderate enlargement of the skull and widening of the sutures. The 
subsequent fate of the infant depends upon whether the process which has 
caused the intracranial accumulation of fluid is arrested or whether it con- 
tinues and even causes an increase in the size of the skull. In the former 
instance it is possible, under favorable conditions, for the central nervous 
2 1 



2 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

system eventually to reach a normal development, the growth of the infant 
in question, mentally and bodily, being such that it differs but little from 
others except in a slightly altered shape of the head. Naturally this possi- 
bility can arise only when the formation and development of the brain does 
not otherwise differ from the normal, and provided there are no sequels of 
the affection, as atrophy, absorption, etc. The absence of these requirements 
will subsequently: reveal itself, provided the infant retains life, by certain 
symptoms of functional defect which may vary from general mental limi- 
tation up to complete idiocy, or may be of a more local nature, involving the 
motor and sensory spheres. But, fortunately for humanity and especially 
for the parents, these cases are very exceptional. The continued increase post 
partum of the intracranial fluid reveals itself on the one hand by the gradual 
but steady enlargement of the skull and widening of the sutures, and on the 
other by such sequels as are brought about by an increased cerebral pressure: 
rapid pulse, vomiting, clonic and tonic spasms, somnolence. The prog- 
nosis of the further course is exceedingly unfavorable. As a rule the infant 
soon succumbs. Puncture and evacuation of the intracranial fluid, so often 
practised in these conditions, usually has but a transitorily favorable result; 
the immediate improvement is soon succeeded by an aggravation. The 
removal of the fluid has merely a symptomatic influence and does not affect 
the cause of the process. Only when this is accidentally arrested can perma- 
nent relief be expected. Nevertheless, in such cases the physician is com- 
pelled to utilize this aid if only for the reason that everything possible must 
be done to maintain the life of the infant. 

A third important clinical malformation in this sphere is the occurrence 
of tumor-like protrusions of the brain and spinal cord, the so-called cerebral 
and spinal hernias. The latter, which is the more common of the two, is 
usually situated in the median line, over the sacrum or at the lower part of 
the lumbar vertebral column (spina bifida, myelomeningocele lumbrosac~ 
ralis). This usually presents a cystic tumor, rarely larger than a walnut, 
flaccid or tense, pointed or flattened, the interior of which communicates 
with the dilated central canal. Externally the tumor is covered by the skin, 
which, if very tense, is more or less thinned, sometimes having a cicatrized 
appearance. Under the skin is the dura. Of the substance of the spinal 
cord either there is none at all in the wall of the sac, or the lower end of the 
somewhat elongated spinal cord is inserted at the inner surface, or separate 
strands are found at the base of the tumor which run along the periphery 
of the sac. At the area of insertion the vertebral arches and the spinous 
processes are defective. Occasionally the sac is already opened at birth and 
has discharged its contents (compression during labor, especially after opera- 
tive interference). Exceptionally the sac-like appendage may be absent. 
The skin terminates peripherally with a tumor-like thickening, centrally 
the tissue shows a funnel-like deepening to the point of entrance in the cen- 
tral canal. Much more rare are similar tumor formations in the region of 
the skull. Here, as a rule, in contrast to the spinal cord hernias, the sub- 



DEFECTIVE AND PATHOLOGIC DEVELOPMENT 3 

stance of the brain is greatly involved. Most often there is a direct protru- 
sion of the dropsical cerebral ventricle (hydrocephalocele) , the cyst wall be- 
ing composed of the scalp, the cerebral membranes, and the brain substance. 
Much less common is a cystic protrusion of the meninges alone (meningo- 
cele), or without accumulation of fluid, consisting merely of cerebral sub- 
stance and the meninges (encephalocele) . The points of predilection for 
all of these forms are the tabular portion of the occipital bone and the lower 
part of the frontal suture, but they have also been noted in the vicinity of 
the great fontanelle, the sutura squamosa, the fissura orbitalis and at the 
base of the skull. 

The prognosis of hernias of the cerebral and spinal cord structures de- 
pends primarily upon the extent of normal development of the central 
nervous system, that is, in how far deleterious influences resulting from 
malformative processes (primary hydrocephalus, etc.) have left their effect 
upon the substance of the brain in the form of atrophy and absorption. As 
both of these factors are usually remote from direct inspection and the 
structure of the skull and the bony canal of the spinal cord in the main 
appear normal, their detection must depend entirely upon clinical observa- 
tion. These tumors may develop further post partum, just as in hydro- 
cephalus, or may retain their original size. In the former case there is 
danger of rupture by direct thinning of the skin from a nutritive disturb- 
ance, such as gangrene. But the condition is serious even if the size of the 
tumor remains stationary. The pressure of the infantile body or the 
manipulations which are necessary in the care of the child readily lead to 
trauma with the possibility of an infectious inflammation, which is always 
exceedingly dangerous on account of the vicinity of the cerebral and spinal 
cord membranes and of the direct communication with the ventricular 
system. 

In an otherwise normal and well-developed child it would seem that an 
operative removal of the tumor, or, in the case of spina bifida, the protec- 
tive covering of the cutaneous defect, should meet all of the requirements 
of the case. Such attempts have been reported from pre-antiseptic times. 
The permanent results, however, are not particularly brilliant even to-day 
when any active infection can almost certainly be prevented and although 
the wound of the pedicle heals by first intention. In most of the cases 
hydrocephalus arises and with the symptoms of this malady the infant per- 
ishes. The majority of cerebral and spinal cord hernias are hydrocephaloid 
and the operative removal of the tumor or the union of fresh edges of skin 
acts only in a systematic manner and is ineffectual as regards the underlying 
process. There is some hope of success, however, in the simple and sta- 
tionary meningoceles, which, as already stated, are the most common forms 
of spinal cord hernias. In any event, if the tumor shows any pedicle and 
does not present conditions too unfavorable for surgical interference, such 
as a cutaneous covering for the pedicle, we should operate, if merely to pre- 
vent injury in the necessary care of the child. By a previous ligation of 



4 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

the pedicle and subsequent careful cleansing of the skin the removal of the 
mass may usually be accomplished without opening the canal of the pedicle. 
In a case of mine of spinal cord hernia operated upon in this manner, the 
wound healed without reaction by primary intention, but in the course of 
ten or fourteen days the development of a hydrocephalus was apparent, to 
which the infant succumbed ten days later. If operative interference is 
impossible on account of the broad-based insertion of the tumor, nothing 
remains but to apply an antiseptic protective bandage to prevent injury and 
infection. 

The deformities of the central nervous system which have been men- 
tioned are clinically the most important on account of their frequency and 
their possible relief by treatment. Pathologico-anatomically they represent 
but few links in the chain> which covers all the gradations from complete 
aplasia to those deviations which may be considered but trifling abnormali- 
ties. It would lead us too far afield to detail all of these. Not only do the 
major deformities and their sequels possess many points of resemblance, 
but the same methods of treatment also prevail. These considerations will 
guide us when investigating the other organs of the body, to which we shall 
now proceed. 

Within the digestive tract malformations are most frequently noted in 
the mouth, the oral cavity, and the anus. The first deformities to be con- 
sidered are congenital clefts, such as those of the lips, known as hare-lip, 
and of the hard and soft palates, known as palatochisis and cleft palate. The 
exact anatomical structure of these individual deformities is so well known 
through embryology and surgery that an accurate description is unnecessary 
and we may proceed at once to their clinical description. Of greatest im- 
portance after birth is a hindrance in proper feeding. In hare-lip this is 
especially marked when the cleft reaches to the nasal opening, the two pre- 
senting a combined opening in which the bony alveolar arch is usually 
involved, the lips being more or less shortened and correspondingly limited 
in their movement. In such cases the firm closure of the lips around the 
nipple, which is essential for the withdrawal of milk, is inhibited or entirely 
impossible, and artificial nourishment by the bottle is necessary. This state 
of affairs is still more complicated when the soft and hard palates are in- 
volved in the cleft formation. The free communication of the nose with the 
cavity of the mouth decreases, even to a greater extent, the efficacy of suction. 
Milk introduced into the mouth regurgitates through the nose. From the 
decomposition of particles which remain in the nose and in the mouth in- 
flammatory processes arise (stomatitis, aphthae, etc.). These deleterious 
agents eventually pass with the food into the stomach and intestines, or into 
the larynx and the lungs by means of the inspired air, giving rise to more 
or less severe catarrhal processes. In addition the inhibited nasopharyn- 
geal respiration results in less warming of the inspired air and its con- 
tamination with dust and other admixtures, which reach the larynx. Breast- 
feeding is sometimes possible in complete unilateral cleft formation, provided 



DEFECTIVE AND PATHOLOGIC DEVELOPMENT 5 

the cleft is narrow and the aplasia of the lips not too decided, and also pro- 
vided the mother or wet-nurse has a well-developed nipple and a profuse 
secretion of milk. Similar conditions are necessary in bottle-feeding: the 
opening in the rubber nipple must not be too small and the nipple itself 
should be of a size to be conveniently introduced into the mouth without 
causing retching and nausea. With a broad unilateral, bilateral, or complete 
cleft formation even these measures are without avail. Feeding by means 
of a spoon or a cup is then necessary, care always being observed that the 
food is carried immediately to the base of the tongue. Prophylactically, to 
prevent decomposing processes, the mouth must be cleansed by a diluted 
boric acid solution. The relief of the deformity can be accomplished only 
through surgery, by the plastic union of the separated layers of tissue. In 
addition to the possibility of these life-threatening complications it is nec- 
essary to consider the external deformity and later the disturbance in speech. 
An early operation, in the first few weeks after birth, is regarded as the 
correct procedure. At this age the child is most apt to be quiet, cries less, 
and sleeps much, and the food requirement is still limited. Only in the 
severe cases with marked prominence of the intermaxillary process do some 
authors advise a postponement until the second year on account of the great 
loss of blood. Severe catarrh of the intestines and of the lungs is of course 
a contraindication; mild disturbances are relieved after a successful opera- 
tion. The previous relief of infectious inflammations of the mucous mem- 
brane of the mouth and of the nose is important. The practical application 
of this operative method is beyond the activity of the ordinary family phy- 
sician and belongs to the realm of the specialist; it will therefore not be 
considered in detail at this point. In this connection reference may be made 
to text-books on surgery. 

The most important malformation of the anus is atresia congenita, due 
to the non-union of the terminal bowel which has been invaginated from 
without with the lower portion of the intestinal canal. In the majority of 
the cases the terminal gut is absent and in place of the usual anal opening 
there is only a moderate retraction of the skin. More rarely the entrance 
of the terminal bowel exists but has a blind ending below the intestinal canal, 
from which it is separated by a layer of tissue. Eoser has called attention 
to the occurrence of simple epithelial agglutination at various heights. 
This deformity is recognized by simple inspection or through the non-dis- 
charge of meconium. The principal danger lies in the decomposition of 
the contents of the intestinal canal by the bacteria which enter with the 
introduction of air and later of food. Just as in obstruction of the bowel 
from other causes, a septic peritonitis may finally develop. Therapeutically 
the only relief is through operation, which should be performed as early as 
possible on account of the threatened calamity. 

When the inhibition in development has occurred earlier, at the time of 
the formation of the cloaca, the conditions are even more complicated. 
Those forms then develop in which the intestinal canal terminates in the 



6 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

bladder or urethra (anus vcsicalis or anus urethralis). Such infants perish, 
soon after birth in consequence of ichorous inflammations of the bladder, 
of the urethra, and of the kidneys. The operative production of a condition 
resembling the norm must be attempted as early as possible, but, as is evident, 
is extremely difficult. 

Of other persistent deformities stenosis of the car&ia, constriction, oblit- 
eration or complete interruption in the course of the remaining intestinal 
canal must be mentioned. The last condition is usually associated with the 
symptoms of adhesive peritonitis, but whether this is the cause or the con- 
sequence of the embryonic disturbance is uncertain. To me the former 
appears to be much more probable. Here the deleterious consequence of the 
intake of food and its digestion — the putrid decomposition of the stagnating 
intestinal contents — is all the more serious because at first the diagnosis is 
impossible and the condition may not be suspected until after the absolute 
failure of all therapeutic measures and only by exclusion. By this time, as 
a rule, the child is so debilitated that even if operation were possible it would 
be entirely useless. The prognosis of these conditions therefore is altogether 
unfavorable. 

Within the urinary apparatus the conditions of most vital importance 
are defective formations of the "kidneys, which give rise to insufficiency. 
The most familiar of these is congenital cystic kidney which is usually bilat- 
eral and consists of a small cystic degeneration. Large tumor forma- 
tion, with great distention of the abdomen, leads to trouble during de- 
livery, causing the death of the child either directly or from the necessary 
artificial aid. Even if born alive the child usually perishes within a short 
time. As a rule a positive diagnosis can be made only by autopsy. Bilateral 
localization by palpation of a tumor in the upper segment of the abdomen 
would suggest the condition. High-graded hypoplasia or complete aplasia 
of both kidneys is only a part phenomenon of a condition present also in 
other organs and necessarily is incompatible with life. The unilateral pres- 
ence of this inhibited embryologic development is commonly compensated 
by a corresponding hypertrophy of the other kidney and thus all damage to 
the development of the individual is prevented. Accordingly the post 
mortem evidence of unilateral hypoplasia or aplasia in an adult is one of 
those interesting surprises which were unsuspected during life. 

In addition to these direct malformations there are many which have a 
secondary, indirect eifect upon the kidney by hindering the off-flow of 
urine. Malformations of the ureter (obliteration, high-graded constriction, 
kinking, valvular closure) result in complete or incomplete hydronephrosis 
of the side involved. If the obstruction is more distally situated, within the 
ureter (complete closure, constriction, stenosis of the external orifice; in 
hypospadia or epispadia or with an otherwise normal development, phi- 
mosis) the bladder will be affected first (over-filling, over-distension) and 
in the process of backward stasis both kidneys will be involved. Whether 
these sequelae will develop intrauterine depends upon the magnitude of the 



DEFECTIVE AND PATHOLOGIC DEVELOPMENT 7 

obstruction. Complete closure must have its effect even intrauterine. On 
the other hand deformities of lesser degree may cause a disproportion of the 
lumen and only gradually appear in extrauterine life under the influence of 
the urinary secretion which steadily increases with the ingestion of food. 
The prognosis depends upon the degree of the renal disease and is, there- 
fore, decidedly more grave in the intrauterine forms and with the involve- 
ment of both kidneys. It is most unfavorable in those very exceptional cases 
in which there are also other malformations and when there is complete oc- 
clusion of the urethra. It is the duty of the obstetrician to inspect the 
channels of outlet at once post partum for an immediate recognition of these 
conditions. The discharge of urine during subsequent days must also be 
noted. In the more marked forms there is also a prominence of the lower 
abdominal segment, due to the distended urinary bladder or to the presence 
of a more or less distinct renal tumor. It is scarcely necessary to mention 
that in the conditions of complete closure of the lower urinary passages which 
in the course of time produce a degeneration of the renal tissue nothing is 
to be expected from therapy. Such treatment is futile, as has already been 
stated, on account of malformations in other vital organs. But even in 
unilateral hydronephrosis an expectant treatment at first is indicated. For 
some time the tumor remains stationary and of moderate size. The newly 
born infant is not in a condition to bear the effects of a serious operation 
and quickly succumbs to shock. An effective treatment is only possible 
with those isolated constrictions at or near the surface. This consists of a 
surgical dilatation. The time for operation depends upon the degree of 
the deformity. For the method of operation recourse can be had to the 
text-books on surgery. 

In addition to the deformities of the urinary organs already mentioned 
there are many others: dystopia (malposition) of one or both kidneys, 
horse-shoe kidney, duplication and abnormal outlet of the ureter, hypospadia, 
epispadia, ectopia vesicae, etc. In the first few weeks of life these are of 
less serious import as they have no influence upon the existence and the fur- 
ther development of the individual. Some of these conditions have merely 
a scientific value at any age or are only of importance in a differentio-diag- 
nostic respect. In hypospadia and epispadia of males sexual impotence in 
later years may require the relief of the malformation provided that techni- 
cally such an operation is possible. Congenital abdominal fissure communi- 
cating with the bladder, in which the prolapsed mucous membrane of the 
bladder is exposed to injury and infection and the adjacent epidermis can 
not be protected from eczematous affections on account of the constant con- 
tamination with urine, is not operated upon as a rule before the fourth 
year or even later. 

Important defects in the development of the respiratory tract occur only 
when there is marked malformation of other organs. A disturbance of the 
respiratory function is brought about indirectly by incomplete closure of the 
thoracic cavity — diaphragm and thoracic wall. Congenital cleft of the 



8 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

diaphragm prevents inspiratory distension of the lungs; with the corre- 
sponding muscular action the adjacent abdominal organs penetrate the 
thorax and the child perishes at once post partum. A similar insufficiency 
results from the various forms of thoracic cleft, the more marked of which, 
as is well known, are associated with complete ectopia cordis. In the latter 
the cause of death may be determined by simple inspection; the former 
developmental deformity can naturally be determined only by autopsy. 

Within the circulatory apparatus the degree of development of the 
heart is of the greatest importance. Complete absence or a functionless 
rudiment is found only in twins from one ovum. The heart of the normal 
twin simultaneously supplies the circulation in the acardiacus (omphalosite). 
The two may be intimately adherent (parasitic) or may be separate (free 
acardii). In the latter form the communication of the vessels is within 
the placenta. The life of the acardii ends with the separation from the 
host, therefore with the free acardiacus at birth, that is, with the tying of 
the umbilical cord. If the parasitic acardii belong to the double malforma- 
tions those which are free present very marked monstrosities (acephalus, 
acormus, amorphus, etc.). 

Of much greater importance than these passive rudimentary structures 
are the developmental defects of the self-acting heart, the so-called congenital 
vitia cordis. Their pathologico-anatomical and clinical investigation we owe 
largely to the labors of the latter half of the past century. According to 
these researches the frequency of this condition has been greatly under-esti- 
mated in former times. The severe forms with absolute incapability of life, 
or a marked disturbance which appears very early, are regarded as rare. 
On the other hand there are a comparatively large number which do not 
show any or but very slight symptoms until a greater corporeal exertion 
(for example, the first attempts to walk) increases the activity of the heart. 

Developmental errors may appear at any stage of the formative period 
of the heart. The earlier their occurrence the greater are the consequences, 
in that a primary deviation results in further defects of development. With 
each advance in the development the circle of this direct influence is nar- 
rowed so that, finally, when the heart has reached the stage of intrauterine 
or fetal completion single anomalies are very seldom observed. 

In the combined or cumulative forms the large arterial vessels (aorta, 
pulmonary artery) are commonly involved. A division of the truncus ar- 
teriosus communis either has not taken place at all or is rudimentary. 
This has occurred at the cost of one of the vessels (atresia or stenosis of the 
pulmonary artery or aorta), or the intervascular wall has taken an abnormal 
course and has connected the pulmonary artery with the left ventricle, the 
aorta with the right ventricle, or both vessels with one ventricle, usually the 
right. Simultaneously, especially with a hindrance in the off-flow through 
the arterial orifices, there is a defect in the formation of the septum atrio- 
rum or septum ventriculorum. In addition, atresia and stenosis may 
result in a patulous or even a more marked development of the ductus 



DEFECTIVE AND PATHOLOGIC DEVELOPMENT 9 

Botalli in order to aid the deficiency in circulation which would otherwise 
arise distally. Finally, owing to the difference in the amount of work per- 
formed because of the abnormal distribution of blood in the heart, one of 
the ventricles may develop beyond the normal extent while the other is 
more or less retarded. It is apparent that in this manner malformations 
may arise which are not equal to the increased requirements at the comple- 
tion of birth, that is, to the change from the fetal circulation. Such infants 
perish during birth or soon afterward from cardiac syncope resembling 
profound asphyxia. Another group survive the first attack but rapidly 
present the significant symptoms of a disturbed cardiac activity. The most 
familiar of these symptoms is blueness of the shin or congenital cyanosis. 
Naturally, this symptom only appears in those cases of developmental defect 
in which there is a further backward flow of the blood into the veins of the 
body. At first, and even later, the regions most markedly involved are the 
face, the ears, the hands, and the feet. The lips, the mucous membrane of 
the mouth, and the conjunctivae may also be distinctly altered. All shades 
are observed, from the deep blue which is conspicuous even to the laity to a 
bluish discoloration of the mucous membrane scarcely noticeable to the ex- 
pert. Crying, vomiting, cough, bodily movements, increase this symptom 
just as complete rest ameliorates the condition. The hands and feet are 
cool to the touch. Should the infant live, club-like swellings develop on 
the nail phalanges (drumstick fingers). Congenital cyanosis is an infalli- 
ble sign of a congenital anomaly of the heart. There are, however, con- 
genital defects of development in which this symptom is absent, i. e., when 
the condition of backward flow into the veins, mentioned above, is not pres- 
ent. The complexion then presents a conspicuously pallid or grayish yellow 
appearance which in later years may readily be mistaken for simple anemia 
or chlorosis. 

Infants suffering from congenital defects of the heart show peculiarities 
in their behaviour and habits. They are more quiet and sleep much. The 
voice is hoarse and without power. The movements are rather sluggish and 
phlegmatic, lacking the ordinary activity. Nursing from the breast or bot- 
tle is very slow, with long pauses as though the child were exhausted and 
suffered from lack of air. In addition to these minor consequences of de- 
creased absorption of oxygen, due to a stasis of blood in the lesser circula- 
tion, there are sometimes attacks of dyspnea, at first perhaps associated only 
with crying, vomiting, cough, etc.; later these attacks occur at short inter- 
vals, without special cause, and are augmented to actual asthmatic attacks. 
If we add to this the tendency to epistaxis, hemoptysis, catarrh of the respi- 
ratory organs, and a lessened resistance to other diseases, especially those of 
the gastro-intestinal tract, we may readily realize how unfavorable is the 
prognosis. The greater number of infants with congenital disease of the 
heart succumb within the first twelve months, and but a very small number 
reach the fifteenth year. Very few survive to an adult age, even to the 
fortieth year or more. Death results either directly from compensatory 



10 DISEASES OF THE NEW-BOHN IN THE FIRST DAYS OF LIFE 

disturbance (dyspnea, dropsy) or from complications, among which gastro- 
enteritis in the first year of life and tuberculosis in later years play the most 
important part. 

For the clinical diagnosis the results of auscultation as well as congenital 
cyanosis are important. The demonstration of cardiac murmurs soon after 
birth is sufficient. Functional and hemic murmurs do not yet arise. The 
appearance of an acute disease of the heart immediately after birth is ex- 
ceedingly rare and is then associated with corresponding constitutional 
symptoms. The differential diagnosis of acquired valvular lesion does not 
come into question until later. Among the important general differential 
factors we find that the murmur of congenital disease is almost always sys- 
tolic in time and most distinct at the base of the heart, not at the apex, 
that the definite auscultatory signs are in marked contrast to the signs upon 
percussion, which are slight or absent, and finally, that the apex beat (the 
impulse) is never increased but rather weakened. The presence of other 
malformations is of some value in establishing a congenital predisposition. 
To enter upon a more explicit description of special deformities and their 
explanation would lead us too far. Such descriptions will be found in the 
works of Assmus, Eauchfuss, Freymann, Lebert, Hochsinger, etc. The 
minute analysis of these combined congenital valvular lesions sometimes 
offers great difficulty. However, the many confirmations of the earlier diag- 
nosis by the necropsy findings prove sufficiently that this object can be met 
by careful study, at least so far as the grosser lesions are concerned. 

In regard to treatment, those measures must first be considered which are 
likely to improve the general condition, therefore proper food, sufficient 
warmth. The great danger of intercurrent disease of the intestines and of 
the respiratory organs requires particular care in the preparation of the arti- 
ficial food and of the necessary utensils (bottles, nipples, etc.), and a careful 
airing of the room. When compensatory disturbances arise minute doses of 
digitalis and strophanthus are of service. Naturally the improvement thus 
produced is only transitory; a permanent, even though partial, restitution 
is beyond all hope. 

In contrast to these combined congenital cardiac lesions the individual 
valvular defects are considered quite rare. Many of them escape observa- 
tion as they give rise to no particular symptoms. The remainder are noted 
when increased effort is required on the part of the circulation (corporeal 
exertion, disease of the respiratory organs, etc.). As the heart has otherwise 
reached a substantive normal development it is able to a certain extent to 
overcome the slight disturbances due to a single congenital lesion. The 
most common of these are: persistence of the foramen ovale, patulous ductus 
Botalli, slight defect of the membranous portion of the septum ventriculorum, 
and finally, changes in the auriculo-ventricular openings, particularly of the 
tricuspid. The general characteristics coincide with those of the combined 
developmental defects already described. In regard to the special symptoms 
reference must be made to text-books on internal medicine. The prognosis, 



DEFECTIVE AND PATHOLOGIC DEVELOPMENT 11 

naturally, is much more favorable. Treatment is only necessary when com- 
pensation fails and is then in accordance with general principles. 

Congenital rupture of the umbilical cord — hernia funiculi umbilicalis 

— must be regarded as a serious defect of development. While under normal 
circumstances the abdominal cavity is closed in the umbilical region by the 
growth of the abdominal walls to a narrow fibrous ring which permits the 
vasa umbilicalia alone to penetrate, there is at times a broad or a narrow 
cleft by which the intestines enter into the lower portion of the umbilical 
cord. Under such circumstances a flaccid, broad, vesicular or pointed tumor 
of the umbilical region is presented, the cord being inserted upon its oppo- 
site side. According to the size of the tumor and the width of the abdom- 
inal cleft only portions of the intestines are protruded or also parts of the 
liver, of the stomach, and of the spleen. In the extreme cases the mass 
without the abdominal cavity may preponderate to such an extent as to 
fully justify the term eventration. These extreme grades are commonly 
associated with other marked malformations which render subsequent ex- 
istence impossible ; some of them intrauterine give rise to difficult labor which 
leads directly or indirectly to the death of the infant in consequence of the 
necessary aid during delivery. After birth the danger of rupture of the 
umbilical cord lies in the composition of the walls of the sac. This con- 
sists only of amnion and peritoneum. The margin of skin is usually at the 
base of the tumor but sometimes even this has not been reached; more rarely 
the skin extends for a little distance over the tumor. The amnion, like the 
umbilical cord, undergoes necrobiosis post partum and if there be a con- 
tamination gangrene may appear. A further consequence is the develop- 
ment of purulent peritonitis, which soon results in death. The only radical 
cure is by operation: a round incision corresponding to the cutaneous mar- 
gin, reposition of the abdominal viscera, and a union of the abdominal wall 
by suture as in laparotomy. This operation may be performed early with- 
out opening the peritoneum provided the amnion does not adhere to it too 
firmly and there are no adhesions of the intestines. The facility of the 
operation, as well as the prognosis, depends primarily upon the size of the 
tumor or the width of the cleft. If the latter is so great that the skin can- 
not be united at all or only with extreme tension it has been proposed to 
utilize the amnion as a cover. This, however, is of little benefit. It is 
better to relieve the tension by loosening the layers of the abdominal wall 
with lateral incisions. Such serious operations, even in well-developed in- 
fants, are never of especially favorable prognosis. They perish soon after- 
wards from shock, even without the symptoms of infection. In the pedicular 
hernial sacs, after reposition of the content the pedicle is tied. Aside from 
the fact that the intestinal wall may be included in this the predisposition 
to umbilical hernia still remains. These obstacles can be overcome only by 
operative incision and suture. If the relatives refuse operation nothing can 
be done but to apply an antiseptic protective bandage, which prevents infec- 
tion on the one hand, and on the other prevents the prolapse of the intestines 



12 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

in consequence of the abdominal press. In the hernias of medium size these 
measures will scarcely prove effectual for any length of time. In the smaller 
hernias a gradual growth of skin is sometimes noted. For the thorough 
closure of a narrow cleft the use of paraffin injection is necessary — a method 
which has been found valuable in congenital umbilical hernia. 

In addition to the varieties with distinct tumor formation the less promi- 
nent forms are of great importance, especially as they readily escape the 
observation of the physician. The lower part of the umbilical cord and its 
insertion into the abdominal wall may merely be abnormally broadened. The 
intestine lies mostly within the abdominal wall or protrudes but little beyond. 
Very often there is a Meckel's diverticulum. In tying the umbilical cord 
at the level of the abdominal skin the wall of the intestine may easily be 
included in the ligature. With the falling off of the cord there is an anus 
praeternaturalis. If the ligature is applied at a distance from the point of 
insertion the dropping off of the cord may leave an opening in the perito- 
neum into which the uncovered intestine may penetrate. The immediate 
consequence is purulent peritonitis. 

In the descent of the ladder of these developmental defects those cases 
yet remain in which there is no actual hernia funiculi umbilicalis but the 
umbilical ring is merely broader than normal. In these cases an umbilical 
hernia develops soon after birth (therefore acquired) which, in contrast to 
the congenital navel hernias, usually protrudes above the umbilical cicatrix. 
In all of these lesser varieties the fundamental principle of prophylaxis and 
treatment depends upon an early recognition of the condition. This is 
greatly aided if the rule is always followed not to tie the umbilical cord until 
the child actually cries. The intestines are then forced forward and smaller 
clefts are more easily noted. Otherwise the treatment is identical with .that 
of larger hernias and consists in operation, the prognosis of which is de- 
cidedly more favorable on account of the slighter intrusion. To prevent a 
later umbilical hernia the navel bandage should be kept on the child for 
three months and the pressure in the umbilical region increased by layers 
of cotton under the bandage. For an umbilical hernia that has already 
developed the use of an adhesive plaster bandage with a pad included has 
been recommended. Good results have been recently attained by peritoneal 
injections of paraffin by which a radical cure appears possible. An attempt 
should be made to ascertain whether these injections would not be equally 
as efficacious if given subcutaneously or subperitoneally, as they are sub- 
mucously in incontinence of urine. 

Finally, malformations of the extremities must be described. Only 
those are of practical interest in which treatment is able to bring about im- 
provement. Among them are the rudiments of superfluous fingers and toes, 
web formation, syndactylia, club-foot, club-hand, congenital dislocation of 
the femur. Although, in the last decades, in the endeavors to better the 
permanent results the necessary operation or correction has been attempted 
as early as possible, it is the opinion of all authors that the first few weeks 



DEFECTIVE AND PATHOLOGIC DEVELOPMENT ' . 13 

are not suitable. In regard to the special operation and the time of its per- 
formance recourse must be had to surgical text-books. 

Thus far we have considered only the defects of special organs or sys- 
tems, but the entire infantile structure at birth may present a lack of 
development or a deficient vitality. This condition, designated general 
debility, is most commonly the result of a premature interruption of the 
pregnancy, of which the most varied diseases of the mother or physical or 
psychical trauma may be the direct cause. Infants born at term are debili- 
tated only as the result of a twin labor, both infants being affected or one 
alone, the other being quite strong and normal. 

Debilitated infants born at full term are exceptional. Deficient nourish- 
ment of the fetus is the usual cause and is due to an extremely unfavorable 
condition of living or a chronic disease of the mother, the deleterious influ- 
ence not being so serious as to cause a direct interruption of the pregnancy. 
Children under 2000 grams in weight and measuring less than 42 cm. are 
regarded as debilitated. The color of the skin, at first of a bright, glistening 
red, gradually becomes pale with a bluish tinge and cyanotic. The deficient 
development of the subcutaneous fatty tissue is shown by a marked wrinkling 
of the skin, which lends to the face a wizened appearance. The dorsum and 
the extensor surfaces of the extremities show a thick growth of woolly hair. 
The sutures and fontanelles are wide, the nails incompletely developed and 
soft, not reaching to the tips of the fingers. The insertion of the umbilical 
cord is below the middle, between the symphysis and the ensiform process. 
In the genital organs of boys the descensus testiculorum is lacking, and in 
girls the clitoris and smaller labia protrude considerably from the but slightly 
prominent labia majora. The most important differences from normally- 
born children are the weak pulse, at first rapid, but later slowed, the super- 
ficial respiration (whimpering rather than crying), the subnormal tempera- 
ture, and the inability to suckle, i. e., to withdraw a sufficient quantity of 
milk from the breast. Children weighing but 1000 grams usually perish 
the first or second day after birth, and in spite of all care those of 1200 to 
1500 grams rarely live. The principal damage is to be found in the defi- 
cient expansion of the lungs, which results in softness of the ribs and a 
relaxation of the walls of the thorax. Upon every attempt at inspiration 
the anterior thoracic wall is depressed by the external pressure of air. The 
limited circulation due to this is shown by marked cyanosis of the skin. 
The gradual decline of the functional activities, which were extremely weak 
from the beginning, terminates in death in the first or second week. A 
child weighing 1500 grams or more may live with a certain amount of care. 
For the prognosis, in addition to the weight the temperature of the body is 
important. The lower the rectal temperature the more serious the outcome. 
Infants who never show a higher temperature than 35° C. (95° F.) do not 
live. The prognosis is more favorable in proportion as the respiration and 
circulation improve and the food is ingested. This reveals itself primarily 
by an increase in temperature and later by a gain in weight. Infants who 



14 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

fulfill these conditions in the third week post partum present in general a 
more favorable prognosis, but it usually requires from six to eight weeks for 
the minus of the congenital debility to be adjusted. Many infants remain 
delicate for years, some of them for life. 

In addition to this danger of weak vitality debilitated infants present less 
resistance and are more susceptible to infectious diseases. This condition 
may be evident in the process of healing of the umbilical cord. Putrid 
decomposition, septic infection of the umbilical wound and thence to the rest 
of the body, is particularly common. There is a decided tendency to the de- 
velopment of aphthae upon the mucous membrane of the mouth and pharynx 
and their further distribution to the esophagus, larynx and intestinal canal. 
The deficient activity of the lungs further predisposes to the development of 
bronchitis and broncho-pneumonia. Finally, the enfeebled circulation often 
leads to the development of sclerema, which distributes itself over large areas 
of the body with a further decrease in the temperature and a slowing of the 
pulse. 

In the treatment of debilitated infants it is necessary first to consider 
their ready susceptibility to low temperatures. Directly after birth they are 
to be bathed once in water at a temperature of 36-37° C. Afterward merely 
simple washings with warm water should be given, exposing only the part 
to be bathed. The same fundamental law of the slightest cooling and the 
greatest possible retention of heat should be observed in regard to the cloth- 
ing. Cotton or flannel is best and should be heated before each change. 
The crib should be kept at a uniform temperature of 32-34° C. by hot bot- 
tles placed alongside and beneath the child. To prevent burns the bottles 
should be wrapped and the clothing next to the child must not be too hot. 
The necessary control is obtained by thermometers placed at the side and 
under the infant. The inspired air should be of the proper warmth and 
the child be not too greatly cooled during dressing, bathing, etc., and the 
temperature of the room should be uniform, between 22° and 24° C. To 
avoid cooling of the air by opening the doors and windows for the purpose 
of ventilation there should be two adjoining rooms in which the child can 
be placed alternately while the other room is aired. The most uniform and 
best warmth for the child is obtained near the stove. In place of the hot 
water bottles thermophor pillows and plates have recently been introduced 
into commerce which retain heat for a long time. 

This method, which is of the simplest, has the advantage that on account 
of the low cost it may be employed by persons possessing limited means. 
It is true the fundamental condition of constant warming of everything 
about the child, particularly of the inspired air, is very incompletely ful- 
filled. That, however, by this means a positive result may be obtained has 
been taught me by a case from my out-patient practice, in which, with very 
limited means, it was possible to maintain a child born between the sixth 
and seventh months and weighing not quite 800 grams. An accurate appli- 
cation of this simple method undoubtedly requires a great amount of trouble 



DEFECTIVE AND PATHOLOGIC DEVELOPMENT 15 

and care. Although by careful observation and the aid of a thermometer 
it may be determined when a change of the heating apparatus becomes nec- 
essary, the constant day and night renewal demands much watching on the 
part of the nurse. Far easier is the use of a bath-tub with double walls 
which may be filled with warm water (Crede). Every three or four hours 
the water must be renewed. Less serviceable, in practice at least, is the em- 
ployment of a permanent water-bath (Winckel) and the object of heat at all 
sides as well as of the inspired air is no better fulfilled by this method. This 
can only be accomplished by incubators, of which quite a number have been 
constructed and recommended in the course of the last few years. The 
earlier apparatus of this kind (Tarnier, Hearson, Odile, Martin) was very 
complicated and expensive but a decided simplification has recently been at- 
tained and their use particularly in well-to-do practice can no longer be 
objectionable. The self-acting heat regulators are a great improvement 
and more certain. There is no place in this article for a minute description 
of the various models and their utility. For this I must refer to the excel- 
lent reports of Finkelstein, Monti, Eommel and Tolano. It must, however, 
be remarked that the value of a closed heating apparatus is not only founded 
on the result of a constant temperature, but that a sufficient quantity of pure, 
unused, and properly moist air must be conducted to the child. For this 
reason direct heating of the introduced air by a gas, spirit or petroleum flame 
is absolutely unsuitable since we are then dealing with combustion or ex- 
hausted air, the quality of which cannot then be improved even by the pro- 
portionate amount of moisture it contains. The only incubator I shall men- 
tion is the older Auward apparatus with which I have had satisfactory 
results. The very tedious and awkward method of heating through cases of 
water is greatly simplified, since the introduction of electricity into houses, 
by the substitution of electric globes. 

Of just as great influence as the retention of heat (to retain the life of 
debilitated children) is the food. The best food unquestionably is mother's 
milk. Children who cannot nurse or do not nurse sufficiently should have 
the milk given to them with a teaspoon. Milk withdrawn by the milk- 
pump from the breast of the mother or wet-nurse and given to the child by 
a tube is not advisable because the necessary cleanliness cannot be observed. 
If the child cannot swallow, nourishment by the stomach tube (Nelaton's 
catheter) is necessary. The milk must be administered to the child every 
three hours day and night in quantities of 20 to 40 grams. With children 
who are able to suckle it is absolutely necessary to control the amount of 
food by weighing before and after the feeding. Should the quantity prove 
too small the lacking quantity must be given with a spoon. In artificial 
feeding it is usually best to give a combination of one part milk and two 
parts thin gruel with some milk sugar. Some authors employ Gartner's, 
Backhaus's, or Voltmer's mixture. Monti and Passini advise one part milk 
with two parts whey. 
• Finally, the pulmonary activity of the infant requires attention. Prophy- 



16 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

lactically a frequent change of posture prevents the development of hypos- 
tasis. Washing of the body with warm water morning and evening with 
slight friction of the skin, together with crying, leads to deeper inspirations 
which decidedly facilitate circulation. If the respiratory movements are in- 
sufficient, raising of the trunk below the shoulders and closing the nasal 
opening a few times during the day are advantageous. Naturally, all of 
these measures must be undertaken with careful avoidance of cooling of the 
infantile body. 

INFECTIOUS DISEASES 

We now come to the infectious diseases which may be transmitted from 
the mother or the father to the fetus. Of these the best known is syphilis. 
The conditions of its transmission and the nature of the symptoms have been 
described in another article 1 . In regard to tuberculosis, up to within a short 
time the view was accepted of a hereditary predisposition which not rarely 
revealed itself externally by a feeble physical development. With advanced 
tuberculosis of the father the secretion of sperm containing bacteria may at 
this time be regarded as proven. There is no pathologico-anatomical proof, 
however, of an actual transmission to the fetus in this early stage of develop- 
ment. In regard to the possibility of infection on the part of the mother 
the conditions are different. Absolutely positive cases of maternal trans- 
mission of tuberculosis have been reported in the last few years by Rind- 
fleisch, Damm, Birch-Hirschfeld, Lehmann, Schmorl and Kochel, Anche 
and Chambrelent, Bar and Eenon. I mention only those authors who were 
able to demonstrate both pathologico-anatomically and bacteriologically an 
actual tuberculosis in the fetus as well as in the mother. In the fetus recent 
as well as older caseous or even calcified tubercle foci were found, the specific- 
composition of which could be demonstrated not only microscopically but also 
by culture, by the demonstration of bacilli, and the pathogenecity has some- 
times even been strengthened by inoculation experiments. The transmission 
by the placenta, as well as the nature and the localization of the specific dis- 
ease in this organ, also forms the subject of these highly interesting investi- 
gations. In some of the cases the disease in the mother was acute miliary 
tuberculosis, in which the complete infiltration of the body, therefore a 
transmission to the placenta and thence to the fetus, appears obvious. In 
addition to this affection, which in the totality of tuberculous diseases is 
quite rare, is the positive finding of tuberculous foci in the placenta in the 
chronic varieties of tuberculous pulmonary phthisis, through which the 
possibility of a maternal transmission to the child attains a certain import- 
ance. In regard to the age of the infant, in a portion of the cases the con- 
dition was found in the fetus at the second half of pregnancy, the mother 
having died in the agonal stage of Caesarian section, or the pregnancy hav- 
ing been for some reason spontaneously interrupted. The fetus was still- 

1 See article on " Hereditary Syphilis." 



INFECTIOUS DISEASES 17 

born or soon perished post partum. In a second variety of cases the infant 
lived for some days or weeks (death between the end of the first and the 
fourth weeks). The tuberculous focus, corresponding to the intrauterine 
circulation, occurs principally in the liver and spleen. Disease of the 
lungs is much less frequent. In addition to these vascular forms there are 
cases of lymphatic distribution, characterized by retroperitoneal, mesenteric, 
bronchial and portal lymjDh-gland tumors. The maternal transmission in 
the severe acute and chronic forms of tuberculosis may therefore be consid- 
ered proven. In regard to the great rarity, however, with which tuberculous 
disease is observed in the first years of life, this result must be regarded as 
exceptional. For the majority of cases, as regards the influence of tubercu- 
losis in the mother, we are dependent upon the view of a hereditary predis- 
position in the sense of a more ready susceptibility to external infection by 
means of milk, air, substances contaminated with sputum, etc. 

In regard to the acute infections, such as variola, measles, and scarlatina, 
we are dependent at the present time for the recognition of the disease in 
the fetus upon the clinical symptoms alone. The properties of the causal 
virus are at this time so little characteristic bacteriologically that it cannot 
be utilized in diagnosis. Intrauterine transmission from the mother to the 
fetus has been proven most positively in variola. Women suffering from 
variola have given birth to premature children, and children have been ob- 
served at term with the pustules of variola or distinct, characteristic cica- 
trices of the affection. Therefore variola of mild form may exist in the fetus 
without causing an interruption of the pregnancy. The transmission and 
the course of the pathologic process do not occur simultaneously with those 
of the mother but usually somewhat later. Whether there is a special tend- 
ency to fetal infection during the stage of suppuration, as some assume, has 
not yet been positively determined. Nevertheless the pustules of variola 
have been found at birth upon the off-spring of women already convalescent 
from the disease, while mothers who were still ill of variola have given birth 
to apparently healthy children who were not affected until a few days later. 
The latter observation forces us to suspect the apparently healthy child and 
accordingly to isolate it. In a twin pregnancy one child may be infected 
and the other healthy. This extremely interesting circumstance seems to 
indicate that there is a lesion in the epithelium of the chorion (Wolff) 
whereby the placenta itself becomes susceptible to the virus. This coincides 
with the fact that in comparison to the total number of births in women 
suffering from variola the intrauterine transmission is exceptional; the pre- 
mature or full-term infants show no signs of this process at birth or sub- 
sequently. Such healthy off-spring of mothers suffering or convalescent 
from variola are always immune to the disease and to vaccination. This in- 
teresting fact which was in former times only conceivable by the assumption 
of a variola running its course in utero without definite localization and its 
results, to-day becomes much more comprehensible through the influence of 
a fetal antitoxin formation stimulated by the maternal disease. This immu- 
3 



18 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

nity of the child resulting from the variola of the mother has stimulated 
attempts to protect the fetus by vaccination of the mother. Judging from 
present results the effect of this process appears to be very questionable, since 
a subsequent vaccination of the child is frequently successful. The influ- 
ence of maternal vaccination, however, cannot be denied entirely as the pus- 
tules in the infant show a slower and slighter development. The best results 
of vaccination occurred in women who had been vaccinated in infancy; the 
poorest results in those whose first vaccination occurred within the last 
fourteen days of the pregnancy. 

Most of the reports regarding intrauterine transmission to the fetus relate 
to measles. In how far the individual case may actually be considered posi- 
tive depends upon the requirements for a positive diagnosis of this affection. 
Clinically the demonstration of a rise in temperature, catarrh, and a cutaneous 
eruption which fades after a few days, with small-flaked desquamation of the 
epidermis, is necessary. In the rudimentary forms one or another symptom 
may be less marked or even absent, but for a positive diagnosis a rise in 
temperature, even though moderate, is probably always necessary. All 
reports must be excluded as unreliable which mention merely a later exten- 
sive desquamation in the new-born infant, therefore, in which an exanthem 
was not present. Desquamation, as is well known, occurs in all new-born. 
Its extent and the time of its appearance is subject to such great variations 
even under normal circumstances that to draw conclusions from it in regard 
to the presence of complications is impossible. Nevertheless there are quite 
a number of reports of an eruption upon the skin which is occasionally 
described as a distinctly characteristic exanthem of measles or is designated 
as macular. The skin of the new-born, however, at birth is of a bright red 
color, which is all the more decided the stronger the respiration and the more 
the infant cries. In the succeeding days the discoloration gradually fades. 
It need scarcely be remarked, therefore, that the recognition of a cutaneous 
affection, the chief characteristic of which is redness, even though distributed 
in a definite manner, must be exceedingly difficult and readily subject to 
error. A positive sign is the temperature curve, but there is absolutely no 
mention of this in any of the reports. Eiiter, who noted a rectal tempera- 
ture of 40° C. (104° F.) in a new-born infant, found no eruption upon the 
skin but only a somewhat more decided desquamation on the fourteenth day. 
As in this case, the mother showed an axillary temperature of 39.5° C. 
(103.1° F.) a transmission of heat to the child may be assumed, particularly 
as the latter after twelve hours was found to be entirely free of fever. If 
there was no rise in temperature in the other cases then the cutaneous 
affection must be placed upon the same level as those which arise from the 
effect of drugs or in consequence of intestinal catarrh; in other words, it 
must be regarded as of reflex or trophoneurotic origin. The cases that have 
been reported are too inadequate to prove an actual occurrence of measles. 
For a definite decision of this question a rise in temperature at least is abso- 
lutely necessary. There are, however, reports of two cases in which, in 



INFECTIOUS DISEASES 19 

addition to the eruption upon the skin, the characteristic catarrh (conjunc- 
tivitis, sneezing, cough) was present. One child (Hedrich) was born with 
these symptoms. In the other case (Heim) the catarrh appeared upon 
the fourth day and the exanthem upon the eighth day, post partum. As 
the minimum period from incubation to the eruption of the exanthem is 
supposed to be thirteen days there would be no objection to considering the 
latter case as one of intrauterine infection. Sneezing is a well-known 
peculiarity of all new-born infants. The other catarrhal symptoms, how- 
ever, are very suspicious, and if there are any reports at all in the literature 
which warrant a diagnosis of measles in the new-born the two last-named 
cases would have to be first considered. In these cases there is no mention 
of a rise of temperature. The opinion of many authors that unquestionable 
cases of genuine intrauterine infection of measles have not yet been reported 
or observed seems fully justified after the foregoing statements. 

The same remark is true in regard to scarlatina. The positive examples 
of an earlier period (Meynet, Asmus, Potier, Ferrario, Pourtual, Gregory, 
etc.) offer too few points of support for the actual presence of this infectious 
disease or do not exclude the possibility of some other method, of trans- 
mission. In regard to the negative results, according to which the child 
remains well, the confusion with a cutaneous exanthem in septic disease of 
the mother, which so often has been the cause of error, is a weighty argument. 
In recent times when the differential diagnosis of the acute exanthemata 
has been especially perfected, the observations of births of entirely normal 
children has become more prominent. Scarlatina, however, is an exceed- 
ingly rare disease in adults and the percentage of cases in pregnant women 
is correspondingly very low. Further, even in variola, the number of cases of 
intrauterine transmission is exceedingly small. If, therefore, a positive 
condition has not yet been noted the possibility of the occurrence of intrau- 
terine infection can by no means be excluded. In all such instances it will 
be well to isolate the new-born child. There is much less danger that the 
infant may be infected by the mother later, as children who are well when 
born usually remain so and therefore in all probability have been immunized. 

Of great importance in the influence of maternal infectious diseases upon 
the fetus are the recent researches in regard to enteric fever (typhoid fever). 
Here, just as in tuberculosis, we are dealing with a pathogenic agent which is 
distinctly characterized bacteriologically. Eeher was the first to obtain 
cultures of typhoid bacilli from the fetal organs, the fetus having been 
born at six months, during the third week of an attack of enteric fever in 
the mother. This finding was soon confirmed by Neuhaus, Chantemesse 
and Widal. Although in these reports the characteristics of the bacilli are 
not so distinctive that they may be regarded as absolutely conclusive, all 
doubt ' is removed by the further investigations of Eberth, Ernst, Hilde- 
brandt and Durk. The first author found the pathogenic agent micro- 
scopically in smear preparations of the blood from the heart, of fluid from 
the spleen and liver, and in the intervillous spaces of the placenta. Ernst 



20 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

showed positive preparations from the spleen, the brain, the bone-marrow, 
the skin, and the muscles of the abdomen and heart; Hildebrandt from the 
spleen, kidneys, liver, mesenteric gland, from the veins of the navel and 
from the blood of the heart. The bacilli were found chiefly within the lumen 
of the vessels, more rarely between the tissue elements. The possibility of a 
post mortem overt! ooding which might have happened formerly wilh the 
simple culture index is removed by this microscopic intravascular finding 
and proves that the transmission to the fetus positively took place during 
life. Pathologico-anatomically every other characteristic local lesion of 
enteric fever, especially in the intestines, was absent in the fetus so that the 
disease must be regarded as a pure general infection, or, as Reher suspected, 
blood tijplioid. The transmission to the fetus in enteric fever after the out- 
break of the maternal disease is apparently somewhat delayed; the cases that 
have been investigated occurred prior to the end of the second week of the 
affection. In how far the intrauterine infection is responsible for the death 
of the fetus in the cases that are still-born is very difficult to decide. In the 
course of enteric fever in the mother there are many complications by which 
the vital force of the fetus may be destroyed, or so far lessened, that the 
deleterious influence of the bacteria needs comparatively slight assistance. 
To this category probably belong those cases in which the absence of any 
reactive change in the infantile body lends to the process of infection rather 
the appearance of a simple overflooding with the toxins of the disease. More 
suspicious are the cases in which there was a distinct parenchymatous 
inflammation of the liver and spleen in the fetus. Of most importance and 
interest, however, are those conditions in which the child was born alive and 
succumbed later, apparently to the consequences of the infection. A case 
of this kind was reported by Ernst: A child born between the thirty-sixth 
and thirty-seventh weeks of pregnancy died suddenly upon the fourth day 
from some undetermined cause with peculiar symptoms (jaundice, eruption). 
At the autopsy no special disease was discovered but bacteriologically there 
was found a flooding of the entire body with Eberth-Koch-G-affsky bacilli. 
In opposition to those positive bacillary findings there are quite a number 
with negative results (Simmonds, Frankel, Kinderlen, Birch-Hirschfeld). 
This proves that the intrauterine transmission is by no means the rule; on 
the contrary, it appears to depend in part upon the local changes in the 
placenta, in part upon the particular severity of the affection in the mother, 
and therefore, upon the increase of bacilli in the intervillous spaces of the 
placenta, and perhaps also upon other requirements at present unknown. 
Recently there have been reports regarding the Gruber-Widal reaction in the 
fetus; the number of positive and of negative results are about equal. The 
observations are highly interesting in which the bacteriologic investigation 
was negative but the Widal reaction positive. It might be supposed that 
only the agglutinating substance was transmitted to the fetal circulation, 
but the observation of Jehle in a twin pregnancy (the bacteriologic examina- 
tion in both being negative, the Widal reaction positive in one) would indi- 



INFECTIOUS DISEASES 21 

cate that a bacillary infection does take place but to such a slight degree 
that it is not revealed by objective examination. It is very difficult to under- 
stand how the resorption of the agglutinating substance could be associated 
with special conditions which on their part are impregnable to bacilli. This 
coincides with the generally accepted view of to-day that the Widal reaction 
is of greater value as regards infection than in immunization. The latest 
period of a positive Gruber-Widal reaction I recently found in a report of 
Krusen to be twelve days post partum. Here unfortunately nothing was 
mentioned as to the condition of the child. If this is to be regarded as a sign 
of health it would also indicate that the child had recovered completely from 
the intrauterine infection. 

On the part of genuine croupous pneumonia, of which Frankel's dip- 
lococcus is regarded as the pathogenic agent, the intrauterine transmission 
must be looked upon as proven. According to the reports two types of the 
disease may be diiferentiated in the fetus. In investigations of still-born 
infants between the seventh and eighth months (Xetter, Birch-Hirschfeld) 
the disease has been found as a general infection. ISTo particular local change 
was discovered microscopically at the autopsy. Frankel's pneumococcus 
could be demonstrated in the fluids of the placenta by means of smear 
preparations and by culture. In the fetus characteristic cultures were ob- 
tained from the venous blood of the umbilical cord, of the liver, and of the 
heart. In the animal experiment the cultures were always highly patho- 
genic. Correspondingly, in infants who were born of mothers ill of pneu- 
monia and afterwards died the pathologico-anatomical lesion was positive. 
In a newly born child which perished "very soon" after birth Marchand 
demonstrated a "quite uniform, dense, red hepatization of the right lower 
lobe and a very profuse pleuritic exudate." Unfortunately no bacterio- 
logic investigation was made. In a case of Birch-Hirschfeld the "entire 
right upper ■ lobe and the posterior part of the right lower lobe showed 
dense pneumonic infiltration and a deposit of fibrin upon the pleura" (the 
infant died in two days post partum). Frankel's pneumococci, in addition 
to staphylococci and streptococci, were found microscopically as well as by 
culture in the pneumonic lesions and in the spleen. The bacteriologic in- 
vestigation of the organs of the mother, who perished soon after delivery, 
furnished the same results. Finally, the pathogenecity and identity of these 
bacteria were demonstrated by the intraperitoneal inoculation of par- 
ticles of the fetal liver and spleen. Both authors incline to the view that 
the infection arose during birth. 

Of other seldom observed infectious diseases the intrauterine infection 
of the fetus has been demonstrated bacteriologically in relapsing fever, 
Asiatic cliolera, anthrax, erysipelas, sepsis and in malaria. A pure general 
infection and the absence of any characteristic local change predominate. 
Only in erysipelas have the development of endocarditic deposits and puru- 
lent peritonitis been observed. 



22 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 



ASPHYXIA OF THE NEW-BORN 

Passing now to the actual act of birth, probably the greatest danger 
which threatens the infantile life at this time is a hindrance of the inter- 
change of gases with the mother. During pregnancy the mother breathes 
for her child. Within the placenta the oxygen which is absolutely necessary 
for the life of the fetus, its structure and growth, and the maintenance and 
activity of the organs, is absorbed from the maternal blood. In the same 
region the excretion of the products of combustion occurs, especially of car- 
bonic acid which remains from the fetal metabolism. The navel artery 
conducts the blood that has been utilized through the umbilical cord to the 
villi of the placenta where it is purified and supplied with new combustive 
material from the umbilical vein in the infantile body. So long as this 
passive supply of the child is sufficient for all requirements the fetus remains 
in a state of apnea, i. e., all substantive respiratory activity is absent. This 
changes at once when the maternal supply of oxygen shows a decrease or is 
arrested. The deficiency in oxygen which then occurs in the fetal blood 
probably irritates the respiratory center on account of the accumulation of 
readily oxidizable bodies, which otherwise undergo further combustion, and 
forces the fetus to compensate for the deficiency by the activity of its own 
respiratory organs. Thus we explain the origin of the first respiration of the 
child after birth under normal conditions. When the uterus with the greater 
portion of its contents evacuated, contracts energetically, the placenta is 
constricted to the smallest extent and occasionally more or less loosened, so 
that the respiratory space of the fetus is decidedly lessened or completely 
obliterated. With the first respiration the thorax dilates, air enters the 
lungs through the nasal and oral openings, and the contained oxygen enters 
into direct relation with the blood capillaries and their contents. The exten- 
sive unfolding of the pulmonary tissue includes an elongation and a dilatation 
of its vascular net, makes possible a more extensive filling of the same, and 
hence decidedly increases the introduction of oxygen. With the first inspi- 
ration the blood is actually drawn from the right heart into the lungs, the 
pulmonary artery dilates, the ductus Botalli narrows and contracts. The 
succeeding expiration forces the blood, which has become arterial, into the 
left auricle. Therefore, with the first respiration the blood pressure in the 
right heart falls, is increased in the left heart, and the foramen ovale, on 
account of its structure and position, closes of itself. From now on the right 
heart receives pure venous blood, the left blood of arterial character. 
Although in this manner the lesser circulation receives, with the first respira- 
tion, its complete formation and absolute division, the mediate effect upon 
the fetal placental circulation is not lacking, since through the comparatively 
great depletion of blood the blood pressure in the umbilical arteries is lowered 
and they contract. Although the supply of ox}^gen to the placenta has not 
ceased entirely it receives a further limitation with the first respiration. 



ASPHYXIA OF THE NEW-BORN 23 

Naturally both occurrences are the more rapid the stronger the respiration 
after the birth of the child. 

The condition is similar when a disturbance of the maternal supply of 
oxygen occurs prior to death. The fetus makes premature respiratory move- 
ments which, on account of the deficiency of air, are without result. It 
can only aspirate what is directly in front of* its nasal and oral openings, 
therefore fetal fluid, mucus, blood, and meconium. The simultaneous effect 
upon the inclusion of the lesser circulation and upon the exclusion of the 
placental circulation, as already mentioned, is rather calculated to increase 
the already existing deficiency in oxygen. Suffocation must therefore occur 
if the obstruction is not soon remoyed and the maternal supply of oxygen 
reestablished, or the child is not released from its airless prison and placed 
in a position to inspire air of itself. With non-oxidation of the fetal blood 
the early irritation is soon followed by a stage of paralysis. In addition to 
the respiration other centers are stimulated to specific activity through the 
deficiency in oxygen. The involvement of some of them is of great import- 
ance in the clinical estimation of this process since it usually precedes that 
of the respiratory center, and when it occurs attention must be directed to 
the condition in time. The best known of these is the passage of meconium. 
At first the result of a stimulation of intestinal peristalsis, it is facilitated 
later, in the soporose stage, by the occurrence of a sphincter paralysis. That 
this symptom is of no value in breech presentation probably requires no 
remark. In head and transverse presentations it is suspicious as it frequently 
occurs first and comparatively early. It is true there are cases of contami- 
nation of the liquor amnii during birth or pregnancy in which the cause 
cannot be found subsequently, the child being born alive. More positive 
criteria are furnished by the condition of the infantile heart sounds. At 
first, by irritation of the pneumogastric nerve, there is a decrease in their 
frequency which, provided it continues, is regarded in obstetric practice, as 
one of the most reliable signals of warning on account of its early appear- 
ance. Under normal conditions a transitory decrease during the uterine 
contractions with strong pains is an ordinary observation, particularly after 
rupture of the waters. This recuperation in the intervals between the pains 
indicates that with the relaxation of the muscles of the uterus the danger has 
passed. Limitation of the respiratory surface of the fetus and the simulta- 
neous encroachment of the maternal blood changes in the intervillous spaces, 
due to the muscular contraction or great compression of the infant skull, 
are the causes which are invoked in explanation according to the stage of 
birth. Continued or even progressively increased slowing of the fetal heart 
sounds below 100 is regarded in obstetric practice as extremely critical. 
The infantile life is in the greatest danger. An inspiratory movement has 
already occurred or is imminent. In the physiologic animal experiment of 
artificial suffocation this decrease in frequency is first succeeded by a period 
of transitory increase with paresis of the pneumogastric nerve. In the 
newly born child and fetus this change, as a rule, escapes observation. The 



24 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

retardation continues while the contracture of the heart simultaneously 
loses in power, becoming slower and weaker until it finally ceases. In con- 
trast to this there are a number of observations in which this stage of pro- 
gressive increase appears alone or is especially distinct and prolonged. 
Strong compression of the infantile skull and brain in a narrow pelvis is 
usually given as an explanation. That this symptom must greatly exceed 
in urgency the decrease in rapidity is obvious from the series of conditions 
founded upon experiment. Although, with beginning deficiency in oxygen, 
the action of the heart is altered first, nevertheless, with a lack of oxidation 
of the fetal blood this organ remains active the longest. If the respiratory 
center is already affected by paresis we often observe only feeble and infre- 
quent cardiac contractions. But even when these have ceased a renewal, 
at least at first, is not impossible. The centers are still in a paretic condi- 
tion which only with a continued deficiency of oxygen, passes into actual 
paralysis and with this death. Finally it must not be forgotten that infan- 
tile muscular convulsions which, even with intrauterine suffocation, precede 
the paresis of the respiratory center, become obvious to the mother by the 
succeeding absolute quiet. 

In addition to this course of intrauterine suffocation with arrest of the 
respiratory movements there is also a possibility, according to the interesting 
statements of Schulze, of a very gradual retention of oxygen in which the 
differences of degree which are necessary to stimulate the cerebral centers 
in question are lacking, the child gradually passing into a soporose state which 
excludes any central reaction. This author has also pointed out that by 
removal of the obstruction and the reestablishment of the placental circula- 
tion the further development of the process can be arrested and the apneic 
existence of the infantile life, with all of its usual intrauterine functions, 
can be readjusted to the normal even though respiratory movements have 
already occurred. 

For this symptom-complex originating through deficiency of oxygen the 
term asphyxia or suspended animation is generally employed. The former 
designation is suitable only for the severer forms. Its inclusion of all 
stages, after the above description, is inconsistent. For all degrees the latter 
designation is more appropriate and correct. 

The question of how or by what means the interchange of gases in- 
trauterine is inhibited belongs to the province of obstetrics. We will, there- 
fore limit ourselves to a simple detail of the factors which come under con- 
sideration. First we should consider a disease of the mother which brings 
with it a deficient oxidation of her own blood — the source of supply to the 
child : disease of the respiratory organs, eclampsia, disease of the heart, great 
blood loss, death. In healthy mothers it is usually the consequence of a labor 
protracted after the escape of the amnionic fluid, due to a constriction of the 
bony pelvis or an unusual rigidity of the soft parts: anomalous pains, pro- 
longed and rapidly successive contractions of the uterus, tetanus uteri or a 
high position of the contraction ring with the expulsion of the child into the 



ASPHYXIA OF THE NEW-BORN 25 

lower uterine segment. If in these conditions the hindrance of oxygen is 
more or less indirect and gradual the compression of the umbilical cord acts 
directly and therefore more rapidly and energetically — either from prolapse 
or because of its rigid looping — and the premature loosening of the after- 
birth is observed as in placenta previa, in the birth of the second twin, ne- 
phritis of the mother, etc. To this must be added the consequences of a 
greater compression of the infantile skull and the brain in contracted pelvis, 
particularly with the rigid and contracted soft parts or with instrumental 
labor. The pressure upon the brain, by producing irritation of the pneumo- 
gastric nerve, causes a slowing of the pulse and with this a decreased circu- 
lation of the blood in the fetal placenta. This cause is much rarer alone 
than in combination w T ith a decrease in the size of the placenta brought about 
by an immoderate effort of the uterus. If, as is usually the case, this is due 
to changes which disappear with relief of the pressure, therefore after birth, 
a permanently increased cerebral pressure may develop in consequence of 
vascular rupture, either due to a marked overlapping of bones or to fissures 
of bone and fractures, causing an intracranial effusion of blood. At the con- 
vexity of the brain these hemorrhages in the newly born child are as a rule 
readily sustained; if they are situated at the base, however, there is usually 
no hope of recuperation on account of the vicinity of vital centers. 

According to whether the intrauterine further development of asphyxia 
has been spontaneously or artificially arrested by labor the infant shows a 
correspondingly slight or grave degree of disturbance. While an infant under 
normal conditions is active after birth, soon makes respiratory movements, 
cries, and presents a bright red color of the skin, the asphyxiated child is 
motionless, the respiration is absent, slight, or incomplete and associated w r ith 
distinct rales, and the color of the skin is bluish or a pale gray, cadaverous. 
In the severe forms a scarcely perceptible palpitation indicates that traces 
of vitality are present. Many even of the milder forms would gradually 
succumb if proper measures were not instituted. On the other hand these 
are most successful the earlier and the more accurately they are employed. 
Therefore a prompt recognition of asphyxia and of its extent is of great prac- 
tical importance. If suspicious factors have been apparent during birth 
or from the nature of the necessary manipulations all doubt is removed by 
the above-mentioned condition of the child after delivery, especially the 
absence of regular and thorough respiratory movements. For an exact de- 
termination of the stage of the asphyxia the question whether or not there 
is cardiac pulsation is decisive. The arrest of pulsation, however, may have 
just occurred, only a short while ago, therefore paresis is present and a quick 
institution of proper measures may invoke the heart to renewed activity. 
The special condition of the cardiac action, whether slow, rapid, or irregular, 
can be utilized just as little as the observation of individual respiratory move- 
ments. The prognosis which has been considered favorable on this account 
has often proved later to be erroneous. Such symptoms are of more value 
in judging the effect of resuscitative measures. As every advance improves 



20 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

the prospect, so is the final result characterized by a regular and complete 
action of both organs. The first and most important point, as we have learned 
to recognize from B. Schulze's excellent description, is the character of the 
muscle tonus. The living muscles, even in repose, present a certain resist- 
ance and rigidity which prevent their immediate response to every external 
action, especially gravity. In the cadaver this condition has given place to 
a general relaxation and lack of resistance. If in the new-born the muscle 
tonus is retained the prognosis may be regarded as good and the condition 
looked upon as a mild degree of asphyxia. The color of the skin is then 
usually bluish red, cyanotic, or livid ; its turgescence corresponds to the norm. 
The heart's action, although occasionally much slowed, is strong. The vessels 
of the umbilical cord are completely filled and maintain an energetic pulsa- 
tion. In the beginning there is no respiration but when it occurs it is at 
first superficial, then deeper, with distinct rales, and associated with a decided 
involvement of the facial musculature. If the muscle tonus has disappeared 
the limbs droop and in particular the lower jaw falls; if upon raising the 
child the head sinks flaccidly to the side or backward we are dealing with a 
severe form, a deep stage of asphyxia. The prognosis is doubtful, rather 
bad and unpromising. The skin is generally grayish, wrinkled, cadaverous. 
The action of the heart, which may be either rapid or slowed, is weak and 
very indistinct. The umbilical cord is pale, empty of blood, collapsed, and 
often stained a light, yellowish green by meconium. Pulsation in the umbili- 
cal cord is either absent or very slight. In this stage the respiratory move- 
ments are observed a few times, but they are superficial, without involvement 
of the facial muscles and with marked retraction of the epigastrium and of 
the lateral portions of the thorax. Of great prognostic importance is the 
reaction of the muscles of the palate. In the active' child this contracts at 
once upon introduction of the finger, but with deep somnolence this effect 
does not occur; there is a flaccid yielding to the pressure of the finger, the 
mouth and the pharyngeal cavity gape and the finger may penetrate deeply 
into the pharynx without resistance. 

The prophylaxis of asphyxia acquired intrauterine belongs to the realm 
of obstetrics. A precise knowledge of the normal, the early diagnosis of any 
abnormalities and the complications to be expected therefrom, that is to say, 
their skillful relief — briefly, the teachings of the special pathology of mid- 
wifery and its therapeutics — are the points which give us the necessary aid. 
In all of the measures which have come under consideration the obstetrician 
must always reflect upon the dangers to which the maternal life is subjected. 
Only this consideration, associated with the fact that the danger of suffo- 
cation of the child will be increased by the operation, and particularly the 
more difficult this be, insures a proper decision and prevents those unfortunate 
failures which also for the mother may have an uncertain or even negative 
result. 

Treatment. — A methodical treatment of asphyxia of the new-born dates 
from the middle of the last century. The knowledge of its origin and develop- 



ASPHYXIA OF THE NEW-BORN 27 

nient, instituted and enhanced by the investigations of Cazeaux, Krahmcr, 
Hecker, G. Veit, Hoogeweg, Schwartz, d'Outrepont, Volkmann, Biirensprung 
and especially of B. Schulze, has furnished the scientific basis by which the 
previous planless and often improper method has been directed into clear 
channels. The principal factors of suspended animation set forth by the 
last author and the indications arising therefrom have been maintained to 
this time. Their knowledge is a necessary prerequisite for a successful therapy. 
The most important sequel of deficient oxygen is the increasing soporous condi- 
tion of the medullary centers which causes the respiration after birth to cease 
and the circulation to become less and less forcible. In addition to this is 
the occlusion of the respiratory passages by aspired masses when respiratory 
movements have occurred intrauterine. With the idea that the free entrance 
of air into the lungs must be made possible some authors (Schroeder, Ols- 
hausen, Veit, Ahlfeld, etc.) regard the removal of the last-named deleterious 
effect as the first requirement. This is accomplished, as is well known, by 
suction by means of an elastic Nelaton catheter. B. Schulze believes this 
to be superfluous. By the swinging movement advised by and named after 
him, which simultaneously fulfills the other requirement to increase the 
circulation and respiration, the removal of inspired material occurs "naturally 
and much more completely." During the expiratory phase the bronchial 
tubes and their branches are compressed, and the substances thus forced into 
the upper respiratory passages and readily expectorated. By suction only 
the upper respiratory passages can he emptied. There the inspired material 
produces rales but does not hinder respiration. The latter occurs in the 
bronchi and their branches which are not influenced by the suction. He also 
regards the prolongation of this measure as an unnecessary loss of time, which 
may readily be serious on account of the steadily increasing sopor of the 
central organs. Admitting all of Schulze's arguments to be correct, a brief 
suction of the upper respiratory passages nevertheless appears to me to be 
proper. By Schulze's method alone, without previous catherization of the 
trachea, the contents of the nose and oral cavity are expelled. The expulsion, 
however, is greatly facilitated and occurs more rapidly provided the upper 
respiratory passages have been cleared. Also there are occasionally tenacious 
mucous substances which cannot be blown out of the catheter without much 
difficulty, therefore their removal by simple compression of the bronchi and 
the aid of gravity is scarcely possible. In short, practical experience has 
taught me that a brief aspiration of the inspired material is decidedly advan- 
tageous. For this purpose, however, the emptying of the nasal and pharyn- 
geal cavities is no less important — a point which is but little or not at all 
mentioned in text-books. This is best and most rapidly accomplished by 
aspiration with a catheter. In man, and particularly in the new-born infant, 
the respiration is predominantly nasal. That with restricted space a displace- 
ment of the physiologic process by the aspired substances may actually take 
place is readly conceivable and in the case in question is very evident from 
the amount of mucus which is discharged. Here an absolute hindrance of 



28 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

respiration certainly never occurs. The mouth is a sufficiently wide expedient. 
Nevertheless in the course of years I have not been able to escape the impres- 
sion that the observation of this precautionary measure is of value, particu- 
larly in promoting a regular, powerful respiration. These preparatory manipu- 
lations of course must not take too long nor be continued unnecessarily. A 
single aspiration through each of the nasal openings from back to front and 
one or, at most, two suctions of the trachea are usually sufficient. The time 
required for this, provided everything has been prepared before the labor, is 
but a few minutes, so that if anything at all is to be done for the asphyxia 
the time can scarcely be regarded as a serious obstacle. 1 

However, the arguments set forth by B. Schulze are neither absolutely 
without objection or entirely conclusive. First of all, the swinging advised 
by him necessarily begins with a dilatation of the thoracic cavity — a point to 
which Schroeder, Olshausen, Ahlfeld, and others have called attention. 
The child is grasped by the shoulders, held downward, and then swung so far 
upward that it doubles upon itself, with, the feet and back toward the physi- 
cian. The expiratory compression of the thorax, therefore, begins at the 
earliest with the bending of the body upward against the diaphragm. Until 
then the distention of the thorax prevails and therewith also of the lungs, 
hence a deeper aspiration of the previously inspired mucous masses is pos- 
sible. It follows, therefore, that the removal of these foreign substances is 
necessary, in so far as possible, prior to the beginning of Schulze's swings. 

Naturally, the essential point of the entire treatment is to increase respi- 
ration and circulation. The regular ventilation of the lungs, i. e., the methodic 
introduction of air which contains oxygen and the removal of exhausted air, 
is the best measure for successfully counteracting the diminution of oxygen 
in the blood. On the other hand also, in so far as the physiologic process is 
fulfilled by an inspiratory dilatation and an expiratory contraction of the 
thoracic cavity, this acts as a stimulant to the circulation of the blood and 
therefore furthers the introduction of oxidized blood into the central organs 
and aids essentially in awakening them from their soporose condition and 
stimulating them to normal activity. In the slighter grades of asphyxia with 
retained muscle tonus it is usually possible to abbreviate this course of de- 
velopment as the central organs still react to strong irritants by spontaneous 
respiratory movements. The above-mentioned aspiration of the upper air 
passages with a catheter has an excellent effect in this direction — another 
reason why the procedure should not be omitted. Other measures that have 
been successful are friction of the back, hot baths, cold affusions, especially 
to the nape of the neck and the epigastric region. In the severer grades of 
asphyxia the proof of an absence of muscle tonus indicates that external 
irritants are ineffectual and useless. Slapping, friction, or whatever else of 
this sort is attempted with the child is an unnecessary loss of time. Here 

1 " But a few minutes " is an eternity in the treatment of asphyxia. Every second 
passed without respiration is a danger to life, or what is worse, a cause of mental in- 
feriority, epilepsy, or paralysis. — Editor. 



ASPHYXIA OF THE NEW-BORN 29 

artificial respiration alone — the above-mentioned regular ventilation of the 
lungs — is of help. Naturally this method must also be employed in the lesser 
grades if other measures prove ineffectual. Among the methods which come 
under consideration two are at present of equal prominence : insufflation of air 
into the lungs, and Schulze's swinging movements. The former, especially 
recommended by Hiiter, Schroeder, and Olshausen, can only be attempted 
with the catheter introduced into the trachea. Direct insufflation of air from 
mouth to mouth or from mouth into the nose leads to inflation of the stomach 
and the contiguous intestines. The hindrance thereby in the movement of 
the diaphragm, that is, the forcing upward of this structure toward the tho- 
racic cavity and the slowing of the heart associated with it, have rather an 
unfavorable effect upon an eventual resuscitation. Insufflation of air through 
the catheter is principally a substitute for inspiration, expiration is induced 
by a manual compression of the lower aperture of the chest which simultane- 
ously aids the upward movement of the diaphragm and therefore must be 
directed backward from above. The chief danger of the insufflation of air 
lies in the laceration of the pulmonary tissue and the development of an 
interstitial emphysema, which, by its special distribution in the hilus and 
thence into the anterior mediastinal space, obstructs the distention of the 
lungs. The strength which is permissible in inflation is very difficult to 
determine. During the period of my assistantship I can remember several 
marked examples of this accident at the autops}^. The operators were physi- 
cians. In the attempt to demonstrate the method upon the cadaver the same 
accident has occasionally happened to me, in so far at least as the beginning 
of this change was detected later. But aside from this complication, accord- 
ing to B. Schulze, the insufflation of air is to be limited alone or principally 
to the respiration. The intrathoracic pressure upon inspiration is increased 
as is the succeeding expiration. By this deviation from the normal the 
simultaneous effect upon the circulation is decidedly limited if not altogether 
illusory. Practical observations as well as theoretic considerations have in- 
clined me seldom to employ insufflation of air as an aid to artificial respira- 
tion. Even in those cases in which B. Schulze advises it — in premature infants 
with very soft thoracic walls — I have not convinced myself of its value. Here 
the insufflation of air is of all the less worth as the insufficiency of the chest 
wall is not relieved but, on the contrary, immediately reappears, and the possi- 
bility of an efficient spontaneous ventilation again comes into question. 

Very important and worthy of consideration for application in general 
practice is the question which Eeich has raised of an ultimate transmission 
of tuberculosis by this method. Within thirteen months ten children perished 
from tuberculous meningitis where a tuberculous midwife had given aid 
during labor. She practised the resuscitation method by the inflation of air 
from mouth to mouth. The use of the catheter would obviate this danger 
but little. Accordingly the suction of mucus from the upper air passages 
must also be highly improper. In addition to tuberculosis the various forms 
of infectious angina, influenza, etc., are no less likely. The danger of infec- 



30 Diseases of the new-born in the first days of lite 

tion is not entirely eliminated if insufflation and the suction of mucus are 
omitted. The intimate contact of the physician or midwife with the mother 
and the child offers sufficient opportunity for transmission. Such persons 
should be prohibited from practising. This assertion is upheld by the recent 
views of Martin and Rosthorn, according to whom follicular angina of the 
physician or of the nurse may very readily give rise to puerperal disease in 
the lying-in woman. The unimportance of finding a method which will per- 
mit these persons to give assistance notwithstanding their disease, but rather 
their complete abstinence, in which lies the greatest safety for the patient, 
is also applicable to the method of insufflation of air. Nevertheless, if I am 
opposed to this method it is only because it appears to me to be inadequate 
and that better methods of artificial respiration are at hand. 

In the mature infant, or one born near term, with a thoracic wall not too 
pliable, Schuhc's method has proved to be essentially better and more reliable. 
This most closely approaches the normal respiratory movements. Although 
the general principle of Schulze's swinging movements is well known, it may 
nevertheless be advisable to enter somewhat in detail into the essential factors 
of the same since deviations are not infrequently encountered in practice which 
show that a complete understanding of the importance of this method is 
lacking. On account of the simplicity of Schulze's description the following 
is quoted literally from his book "Suspended Animation of the New-Born." 

"After the umbilical cord has been severed the infant is grasped at the 
shoulders, between the two hands, so that the thumbs rest against the anterior 
surface of the thorax, the index fingers in the axillae, and the remaining 
fingers across the back. The head, which would otherwise fall flaccidly, finds 
a comfortable support between the ulnar borders of the opposed 'palms of the 
hands. In this manner the obstetrician, who stands with somewhat separated 
legs and slightly inclined upper body, holds the child in front of him with 
his arms extended downward. Without a pause he swings the extended child 
from this hanging position upward. When the arms of the obstetrician are 
raised somewhat above the horizontal he halts the movement so gently that 
the child's body is not thrown forward but slowly sinks forward and the 
weight of its pelvis strongly compresses the abdomen. The entire weight of 
the child at this moment rests upon the thumbs of the obstetrician which are 
upon the thorax. Special care must be observed not to compress the thorax 
by the grasp with which the child is held; the body rests with the floors of 
the axillary cavities upon the index fingers exclusively. There must not be 
either a lateral compression of the thorax, although the ulnar borders of 
the hand offer a firm support to the head, nor must the thumbs press the 
thorax anteriorly. In the upward swing a flexion of the vertebral column 
in the thoracic area should not occur. This must take place almost exclu- 
sively in the lumbar region; the thumbs, even now, should not make decided 
pressure upon the thorax but should only form a support for the infant's body, 
which slowly inclines forward. The uplifting to the horizontal is accom- 
plished by a powerful swing of the arms at the shoulder-joints, then the rais- 



ASPHYXIA OF THE NEW-BORN 31 

iny of the arms must gradually become slower and by carefully measured 
movements in the elbow-joints and movements of the shoulder-blades upon 
the body the operator regulates the gradual inclination of the lower part of 
the child's trunk. By this gradual forward inclination of the child's pelvis 
over the abdomen considerable compression of the organs of the thorax, on 
the part of the diaphragm as well as of the walls of the chest, takes place. 
After the forward inclination of the child has been completed the obstetrician 
moves his arms downward between his extended legs. The body of the child 
is thus extended in one swing; the thorax, free of all pressure (the thumbs 
of the obstetrician now lie quite loosely upon the anterior wall of the chest), 
will now dilate on account of its elasticity, but more particularly because 
the child rests with its upper extremities upon the index fingers of the obstet- 
rician and the sternal ends of the ribs are fixed thereby, the weight of the 
body with a quite decided swing being utilized in raising the ribs. The 
diaphragm also inclines downward with this sw^ing, as is noted by the con- 
tents of the abdominal cavity. Thus a decided inspiration results in a 
purely passive manner. After a pause of a few seconds the child is 
again swung upward to the previous position, and, when it slowly inclines 
backward with its entire weight upon the thumbs which press upon the 
anterior wall of the thorax, mechanical expiration results anew." 

It is of great importance that the child is loosely encircled so that the 
thorax is not compressed and constricted in the changes which take place. 
This is particularly necessary in the inspiratory phase in which all results 
would otherwise be impossible. Sometimes the head falls forward unnoticed 
and by bending limits the introduction of air. Finally, throughout B. 
Schulze's description there is the particular caution that all swinging should 
be "gentle," not forcible, but skillful. During this swinging great external 
force may accidentally be exerted upon the organs of the abdomen, the walls 
and the contents of the thoracic cavity. Aside from fractures of the ribs and 
of the clavicle, in the autopsy reports injuries to the internal organs are men- 
tioned to which the death of the child was referred. Eunge observed effusions 
of blood in the adrenals from the size of a cherry-stone to that of a hazelnut, 
also a complete destruction of the upper lobe of the left lung by an enormous 
hemorrhage with rupture of the pleural covering. Winter reports a case of 
rupture of the liver with hemorrhage into the abdominal cavity and another 
of complete separation of a syphilitically enlarged spleen. Korber and Koffer 
report similar observations of subserous hepatic hematomata and rupture of 
the liver with effusion of blood into the abdominal cavity. Gebhard reports 
the tearing of the pleura over the head of the second rib with hemorrhage into 
the thoracic cavity. B. Schulze strongly objected to the view that these un- 
fortunate accidents were the result of his method. Subserous and parenchy- 
matous effusions of the liver, to which Eokitansky, Forster, and Weber called 
attention prior to Schulze, are common and quite typical findings of severe 
and fatal asphyxia, and their development is the direct consequence of the 
constantly increasing congestion in this organ. Schulze's method acts in oppo- 



32 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

sition to this, for in addition to stimulating the activity of the lungs it me- 
chanically aids the circulation of the blood, particularly that which accumu- 
lates in the veins, corresponding to the position of the cardiac valves, by 
forcing it into the arterial circuit, thus making possible a further compensa- 
tion in the capillary tracts in the lungs as well as in the rest of the body. 
It is true, a tense hematoma may rupture as the result of shock to the body. 
That it may, however, resist the swinging is illustrated by a case of Koffer's. 
Here rupture took place later, upon the seventh day, and most likely, ac- 
cording to B. Schulze, in consequence of an injury at the base of the skull; 
respiration again became difficult and caused a renewed hepatic congestion. 
These and similar hematomata of other abdominal organs may be regarded 
as unfortunate and unpreventable complications which have no causal relation 
with the swinging. 

A second series of unfortunate cases is referred by the authors themselves 
to their forceful management of the child. Chief among them are fractures 
of the ribs and of the clavicle; but injury to the organs is also possible. In 
addition to the marked swinging over the abdominal side in the expiratory 
phase, particularly with heavy children, the absolutely necessary upward 
swinging appears no less dangerous when the body falls back again, par- 
ticularly if the obstetrician does not at once note this error and instead of 
permitting the body to decline holds it up, although only for a brief time, 
by the shoulders. As is shown by the consequences of corresponding trauma 
in adults, the parenchymatous organs, rich in blood (liver, kidneys), which 
are situated in the posterior part of the abdominal cavity, are hereby espe- 
cially endangered. Such injuries, however, can be avoided by a cautious em- 
ployment of the method. If to this we add that these accidents, in compari- 
son to the frequency with which Schulze's method is practised, are extremely 
rare, there can be no objection to the employment of the method in a given 
case, naturally, with the necessary prerequisite that the practical application 
and the theoretic comprehension have been successfully worked out. 

Another method of artificial respiration is faradization of the phrenic 
nerve, first mentioned by Bar and Pernice. This is limited to the periodic 
production of inspiratory contractions of the diaphragm. To prevent a still 
deeper suction of the aspirated material the previous use of the catheter in 
the air passages is necessary. In the severer grades of asphyxia of the new- 
born a sufficient dilation of the thoracic cavity by contractions of the dia- 
phragm is very much questioned by B. Schulze on account of the complete 
relaxation of the remaining muscles of the body and the ready flexibility of 
the ends of the ribs. Besides, there is no stimulation to expiration, the most 
important motive power of intrathoracic circulation of the blood. Finally, 
the obstetrician would seldom have the necessary apparatus in working order, 
nor is it possible that he would always have it at hand. 1 

1 The editor cannot but deem the last sentence a little naive. The following from A. 
Jacobi, Therapeutics of Infancy and Childhood, 3. ed., page 84, may be found welcome. 
Electricity was recommended in cases of asphyxia as early as 1793 by Hufeland. But the 



ASPHYXIA OF THE NEW-BORN 33 

The best and most successful methods for resuscitation in use in adults, 
Marshall Hall and Sylvester's methods, are of much less value in the new- 
born than Schulze's swings. Marshall Hall places the infant upon its abdo- 
men and first turns it slowly to the lateral position or a little beyond and then 
rapidly back again upon the abdomen. These movements are repeated about 
fifteen times per minute. Compression of the thorax by means of the body 
weight enforces expiration in the one phase while, with an arrest of the pres- 
sure, inspiratory dilation of the thorax occurs in consequence of the elasticity 
of the walls. The first action is opportunely aided by pressure upon the back 
between the shoulder blades or on both sides of the thoracic wall. Sylvester 
forces the inspiratory distention of the thorax by decided tension of the 
muscles of the arm and thorax, particularly of the pectoralis major. The 
infant is laid upon its back and somewhat elevated at the shoulders. While 
an assistant holds the feet the obstetrician slowly abducts the arms arch-wise 
to the head. The expiratory emptying of the thoracic cavity occurs by rapid 
adduction of the flexed arms to the sides of the thorax which simultaneously 
is slightly compressed. These manipulations also are repeated about fifteen 
times per minute. To prevent the tongue from falling back and closing the 

first case in which the rhythmical faradization of the phrenic nerve and its associates 
was resorted to (by Ziemssen) for the purpose of producing artificial respiration was 
that of an asphyctic girl poisoned by carbon oxid. The phrenic nerve acts on the 
diaphragm. Its aids are the cervical plexus, which controls the trapezius, levator 
scapulae, and middle scalenus muscles, and the brachial plexus. The ramifications of 
the latter are the anterior thoracic nerve for the pectoralis major and minor; the 
posterior thoracic for the middle scalenus posterior superior serratus, and the rhom- 
boid muscles; and the lateral thoracic for the serratus anticus major. 

In asphyxia of the new-born, the systematic faradization of the phrenic nerve was 
first employed by Lauth and Pernice. 

The point of application selected by most authors is near the sterno-cleido-mastoid 
muscle, over the phrenic nerve. The other pole is applied either to the neck or to the 
diaphragmatic region or any other part of the surface. The localization of the effect 
to the phrenic nerve alone, which was insisted upon by many, is certainly an illusion. 
The current will surely strike the pneumogastric, phrenic, sympathetic, and many sen- 
sitive and motory nerves at the same time. As this cannot be avoided, as indeed it 
is better that it should be exactly so, it is best to use large sponge electrodes and 
moisten them thoroughly with salt water. The head, arms, and shoulders should be 
slightly raised, and a small pillow placed between the shoulders for the asphyctic baby 
to rest on. One of the electrodes must be kept stationary, the other brought into con- 
tact with the surface a single moment only. A deep inspiration will then take place, 
the lungs will expand, and lateral pressure on the lower part of the chest should be 
resorted to for the purpose of emptying the lungs afterwards. Another application 
is then made with the same result, and must be followed by the same manipulation. 
This has to be continued until the baby cries, and until it appears safe to discontinue 
the application. Whenever a cough or a coughing movement is noticed, it should be 
omitted temporarily. The favorable result is, however, not always permanent. The 
causes of the asphyctic condition are still active, and the infant will require resusci- 
tation again, and perhaps many times. That is why close attention must be paid, 
sometimes for hours. 

Great care should be taken in regard to the duration of the application. Continued 
or too frequent irritation by the current causes over-irritation and paralysis. Not in- 
frequently the immediate effect is a favorable one, inspiration becoming deep and the 
4 



34 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

larnyx that organ should he drawn forward. Behm, Champineys, and Schauta 
have tested the effect of these methods on the cadavers of infants and com- 
pared them with Schulze's swings. The first two authors reached the con- 
clusion that Sylvester's method is decidedly preferable. Schauta, on the other 
hand, obtained five or six times better results with Schulze's method and 
accounts for this deviation by an improper performance of the swings by the 
other two authors. Sylvester's method has the great disadvantage over 
Schulze's swings of absolutely demanding an assistant and is therefore de- 
cidedly less suitable in practice. This is also true of the less effective Pro- 
chownich method, in which the child is held upright by the legs by a second 
person while the obstetrician compresses the thorax. 

Lah's method — periodic flexion and extension of the trunk of the child, 
who is held by the buttocks and shoulders — may be well employed in the warm 
bath to aid respiration. Schroeder's proposition appears to be even better : 
After flexion over the anterior side, to somewhat hyperextend the infantile 
trunk by slightly raising the back of the child with the supporting hand. 

Rhythmical contractions of the tongue, practised manually with a cloth 
or forceps and first advised by Laborde, were once much employed. Stimula- 

heart active, but after a short time the former grows more superficial, the pulse feeble, 
and the cyanotic hue returns to the lips and finger-nails. Then it is time to stop for 
a while, and resort temporarily to other means of resuscitation. The practice of Lauth, 
who applied the current persistently for two or three minutes, is decidedly improper 
and dangerous. 

In some cases, where the interrupted current is ineffective, the galvanic (continuous) 
current, with occasional reversions, has been known to yield better results. In my own 
cases I have never had an opportunity or been under the necessity of employing it. 

The application of large sponge electrodes may not always be convenient. In those 
cases no harm is done by using the metal poles instead. Though the irritability of 
the brain (and nerves) is low in the newborn, the pain produced by the interrupted 
current thus applied is very intense, and the effect on the contraction of the diaphragm 
quite marked. That is why it is not necessary to lose time in preparing, if it be not 
on hand, the more complicated apparatus. Still, exhaustion is more readily obtained 
through resuscitating by pain and muscular action combined than by muscular action 
alone. In most cases, however, I was satisfied with not losing even a fraction of a 
minute, particularly in those early times, when the most convenient apparatus was 
the old-fashioned rotating machine. 

How long is the asphyctic baby to be watched and the attempts at resuscitation to 
be renewed? At all events, they must not be given up so long as the heart-beats are 
audible, though ever so feebly. Nor is a single scream sufficient to permit watchful- 
ness to be relaxed. The deep recession, during inspiration, of the diaphragmatic region 
(the peripulmonary groove of Trousseau) should have ceased, the cry be vigorous, 
the eyes wide awake, and the extremities in lively motion. Before this is accomplished 
there is danger of a relapse, partly from impaired innervation and the continuation 
of some of the causes of asphyxia, and partly from obstruction by mucus, which may 
be coming up constantly and gather in the pharynx and posterior nares. 

Some cases of asphyxia are particularly troublesome; those in which it is due to 
prematurity of the newborn or to an actual anatomical change (hemorrhage, compres- 
sion of the brain or medulla) which requires time to get well or will terminate fatally; 
also those which are due to congenital anomalies of the organs of circulation or res- 
piration (syphilis of the lungs, effusion into the pleural or peritoneal cavity, thoracic 
tumors, etc.). — Editok. 



ASPHYXIA OF THE NEW-BORN 35 

tion of the nerves of the palate, pharynx and tongue was supposed to produce 
reflex respiratory movements. As already mentioned, the reflex of the pharyn- 
geal and palatine muscles is the last to disappear. Therefore success is to 
be expected only so long as this reflex is retained, i. e., in the first stage of 
asphyxia. Later, all such attempts would cause an unnecessary loss of time. 
In conclusion, in a brief review of the methods for the treatment of 
asphyxiated new-born with a special consideration of their differences in 
grade the following arrangement will prove serviceable. The first require- 
ment is the proper preparation of all the necessary utensils for resuscitation. 
A plentiful supply of hot water and the warming of all diapers should be 
the first care and the strict duty of the nurse at every labor. It will be well, 
however, for the obstetrician to convince himself that everything is in readi- 
ness so that at any moment (particularly before an operation) the required 
articles will be at hand. After delivery every moment is valuable and any 
oversight may cause a fatal loss of time in the case of an asphyxiated child. 
A lack of this precaution makes the physician just as liable as the nurse, 
perhaps even more so. Of equal importance is the previous preparation of 
a place to lay the child after the cord has been severed so that it may be 
handled. A simple table supplied with a hard pillow or with a blanket 
folded several times and covered with fresh linen or a towel, is usually suffi- 
cient. Upon this one or two catheters and a few warm diapers or towels 
are to be placed. In addition a hot bath at a temperature of about 40° C. 
should be prepared and alongside of this a vessel containing cold water. 
For a quick control the bath thermometer had best be placed in the bath- 
water. Katurally, there should be an additional plentiful supply of hot 
water so that with a prolonged operation the bath may be kept warm. If 
the child does not breathe after birth the pulsation of the heart must be 
immediately noted. If this is normal and strong, not slowed, and if the 
child reacts to blowing by contraction of the facial muscles, the employment 
of slight cutaneous irritants (friction of the back, quick slaps upon the but- 
tocks, sprinkling with cold water) will soon bring about respiration and 
cause the child to cry. There is then no necessity for haste in tying the 
umbilical cord; it is better to wait until the pulsation in the cord ceases. 
If the child does not react to blowing in the face, if the pulsations are slow 
and weak, the cord should be tied at once. The degree of asphyxia is quickly 
determined by introduction of the finger to the root of the tongue. If a 
contraction of the palatine and pharyngeal muscles occurs the stage is mild 
and the asphyxia can be overcome. The catheter is introduced into the nasal 
opening and the pharynx cleared, then the cavity of the mouth, and if respi- 
ration has not yet occurred, also the trachea. If the respiratory movement 
still fails to appear the child should be placed for a short time in a hot bath 
of a temperature of 36° to 38° C, the action of the heart observed, and the 
thorax rhythmically compressed a few times according to Schroeder's method. 
If all of these measures are without result Schulze's method must be prac- 
tised at once. After this has been repeated from eight to ten times the 



36 DISEASES OF THE NEW-BOKN IN THE FIRST DAYS OF LIFE 

child should be placed for a short time in a hot bath to prevent too great 
cooling, the respiration and circulation are observed, and the former rein- 
forced during the bath by the method proposed by Schroeder. If the car- 
diac activity has been increased, if it has become more rapid and stronger, 
if the skin begins to redden, or superficial respiration, even though quite 
irregular, is noted, the time has arrived for the successful employment of 
the previously mentioned cutaneous irritants (friction, cold ablutions). If 
inspiration occurs during Schulze's swings their performance is discon- 
tinued and the child is at once placed in the warm bath for further observa- 
tion. Naturally all of these measures must be continued until the respira- 
tion is sufficiently deep and regular and the child begins to cry, or until there 
is evidence that further effort will be useless, therefore that the activity of 
the heart is decidedly lessened or altogether lost. This is usually apparent 
within one or two hours at the latest. The permanent although slow increase 
of cardiac action is the only favorable sign; the improvement is often transi- 
tory. Unfavorable indications are the complete arrest of spontaneous 
respiratory movement or occasional spasmodic inspirations with marked 
retraction of the lower portion of the thorax. These are purely muscular 
spasms which have no connection with the therapeutic measures and have 
been proven to have no influence upon the amount of air contained in the 
lungs. Correspondingly their appearance coincides with a decrease in car- 
diac activity. Thereafter further attempts at resuscitation are quite hopeless. 

This intra partum asphyxia is contrasted by some authors with the 
second form occurring after birth. Placental respiration is entirely undis- 
turbed and not until complete development does the impossibility of a sub- 
stantive activity of the respiratory organs arise. The cause may depend 
primarily upon developmental anomalies, therefore, as already set forth, it 
may be due to defective development of the central nervous system, of the 
heart, of the diaphragm, of the walls of the thorax, or to the incomplete 
structure of premature infants. There are reports of compression of the 
trachea by congenital goiter or a particularly marked hypertrophy of the 
thymus gland, but in many respects the latter effect is still very doubtful. 
Local diseases mostly of syphilitic nature and developing intrauterine must 
also be considered: pneumonia alba, bilateral pleuritic effusions. An enor- 
mously enlarged liver may decidedly limit the movements of the diaphragm. 
Finally, the results of injury to the skull during birth must be mentioned 
(narrow pelvis, forceps, extraction of the head), the respiratory center being 
directly or indirectly involved by a simultaneous effusion of blood. 

The clinical symptoms of post partum asphyxia are very similar to the 
form acquired intrauterine, namely, feeble or absent respiration with a still 
palpable cardiac contraction. Usually the process is such that after a few 
attempts, sometimes superficial, sometimes very spasmodic, the respiration 
ceases, or its irregular type is maintained for a time with long interrup- 
tions. On account of the undisturbed intrauterine course the respiration 
is free of rales, but this may also be the consequence of ordinary asphyxia. 



TRAUMA DURING BIRTH 37 

Cardiac action, at first normal and strong, soon takes part in this decline, 
becoming slower and weaker, perhaps with a transitory increase. The other 
early symptoms usually correspond to the characteristic first degree of intrau- 
terine asphyxia and pass rapidly or very gradually, according to the cause, 
into the second or paretic stage. The most important point in diagnosis is 
that close observation of the course of the labor reveals not the slightest 
cause for the development of this disturbance. Apart from the similarity 
of the clinical course the fundamental causes, as mentioned above, are 
usually unrecognizable. The only exceptions are in the case of develop- 
mental defects with distinct external deformity, and especially in premature 
infants. Accordingly none of the other cases are regarded as asphyxia in the 
ordinary sense, the etiology being cleared up post mortem. The prognosis 
depends upon the ability of removal of the underlying cause, and therefore 
in the great majority of cases may be regarded as unfavorable at the onset. 
Among the conditions from which recovery may be anticipated, in addition 
to the slight grades of prematurity, we must include congenital goiter and 
hypertrophy of the thymus gland, provided the general condition of the 
child permits of operation. The prognosis may be determined by the degree 
of the disturbance and the rapidity of its increase. In treatment all of those 
previously mentioned factors come under consideration which are of service 
in stimulating respiration and circulation. With a rapid cessation of respi- 
ration the severest treatment, Schulze's swings, must be employed; in the 
milder grades we may limit ourselves to the warm bath, cold affusions, and 
friction of the skin. That external deformity cannot be treated in this 
manner need scarcely be stated. The special treatment of premature infants 
and the eventual prophylaxis have already been explicitly described. In 
congenital goiter and hypertrophy of the thymus gland only operative 
removal (extirpation or resection with eventual fixation of the pedicle to 
the sternum) can be considered for a permanent cure, of which a few excel- 
lent examples have been submitted, although from a later period of life 
(Konig, Rehn). 1 

TRAUMA DURING BIRTH 

We now come to a description of trauma, to which the child is exposed 
during birth. The greatest number of these accidents are due to narrow 
pelvis. With a spontaneous labor the injuries are usually of a mild nature 
and are rarely dangerous to life or to health. The severest trauma results 
from artificial delivery by means of forceps, version, or extraction. The 
most common lesions are of the head. Its preponderance in size is not rarely 

1 From much experience with enlarged thymus glands occurring during (lymphatism) 
later months I suggest careful attention to the posture of such babies. The thymus 
will fall backwards when the baby is on its back, and relieve the trachea when in a 
less recumbent posture. For many years past I could demonstrate the presence or 
absence of an extensive dulness behind and below the manubrium sterni in their con- 
nection with the posture of the child. — Editor. 



38 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

increased by an inelasticity. Even with simple labor pains the pressure of 
the descending head against the promontory of a flat pelvis, and rarely also 
against the symphysis, may give rise to contusions of the skin which are 
designated obstetrically as pressure marks or pressure streaks. Of oval or 
more circular shape the former have their typical localization upon the pos- 
terior portions of the parietal bone corresponding to the angle of the great 
fontanelle. From here the pressure streaks pass to the temporal region, 
usually parallel with the coronal suture, more rarely in a concave direction 
anteriorly. If during the descent of the head the face is also exposed to 
strong pressure a pressure streak may be found with slight deviation to 
the region of the ear and even to the cheek. A single pressure mark is always 
due to the promontory. If it is found upon both sides of the head the 
slighter one is due to pressure against the symphysis or to a neighboring area. 
It is then found either upon the frontal bone or in the region of the eyes 
and cheeks. From a comparison of spontaneous labor with that terminating 
artificially we know that the consequences of this compression of tissue are 
influenced less by the force than by the duration of the pressure. All 
kinds of injury may be observed, from simple redness of the skin with slight 
desquamation of epithelium to more or less intense suggillations and necrosis. 
The time of recovery accordingly is subject to great variation. All traces of 
the milder injuries have disappeared after two or three days, but for the 
complete healing of the more extensive lesions a long time is required, with 
demarcation, formation of granulation, and cicatrization. If the injury 
extends to the periosteum and becomes necrosed an adherent cicatrix remains 
which is distinctly visible in later life and occasionally very sensitive to 
pressure. None of these lesions, even of more severe grade, as a rule leaves 
any deleterious effect upon the child if the necessary cleanliness is observed 
and infection prevented. In the main, therefore, the treatment is limited 
to the employment of indifferent or mild disinfecting salves (boracic acid 
vaselin, zinc vaselin, and dermatol vaselin). 

From these typically situated pressure marks the cutaneous changes must 
be differentiated which are caused by the tearing of amniotic or so-called 
Simonartfs bands. Of round or occasionally more irregular form, they at 
once, present defects which, free of necrosis or demarcation, are limited to 
the superficial layer. If the separation occurred shortly before birth the 
wound appears quite fresh, as if made with a chisel. Otherwise it may already 
be granulated or even in a cicatrized condition. Its localization is not sub- 
ject to special conditions, but may occur anywhere upon the Infantile body. 
In the numerous examples at hand special preference is perhaps shown by 
the region of the occipital protuberance. In the treatment of wounds which 
fail to heal the ordinary surgical measures must be employed. 

Finally, direct contusions of the skin may result from mechanical extrac- 
tion in those areas where the apices of the forceps have been applied: upon 
both temples when the head is grasped transversely; when grasped obliquely, 
on one side upon the forehead above the eye, on the other behind the ear. 



TRAUMA DURING BIRTH 39 

Usually the damage amounts to a simple redness with desquamation of the 
epithelium and disappears upon the second or third day. Hemorrhagic sug- 
gillations and deep necrosis are rare and only the result of too great com- 
pression by the forceps. With an oblique application of the forceps to the 
head one part of the instrument may be placed directly over the eye and a 
moderate pressure may cause an edematous swelling of the upper eyelid. 
With strbng pressure there may be compression and laceration of the 
organ. Pressure of the forceps behind the ear very often damages the 
facial nerve at its point of exit from the stylo-mastoid foramen (facial 
paralysis). A very disagreeable situation arises when the ear is enclosed 
by the forceps and fixed in such a manner that removal of the instrument 
prior to birth of the head becomes difficult or impossible. Under such 
circumstances unskilled and forcible attempts at removal may lead to 
very serious injuries of the external ear and its insertion. The measures 
to prevent injury to such soft parts by the forceps are provided by the 
rules for their proper use. The treatment of facial paresis will be con- 
sidered later. 

A special position among the injuries to the soft parts of the infantile 
head is assumed by the typical accumulation of blood between the pericra- 
nium and bone, the so-called cephalhematoma nar J i^oxrfv. Although 
with narrow pelvis this results occasionally from a traumatic lesion of the 
bone, especially a fissure, in the majority of cases it occurs in spontaneous 
and even easy and rapid labor. Some authors regard its development, simi- 
lar to that of the ordinary tumor of the head, as the result of pressure dur- 
ing birth, causing a hyperemia of the infantile skull which is increased by 
a simultaneous asphyxia or complicated by a greater tendency to tearing of 
the vessels. They base their opinion principally upon the fact that every 
head presentation shows subperiosteal hemorrhages of mild degree in the 
course of the deepest segment. This, however, leaves completely unexplained 
the development of cephalhematoma in the head in a breech presentation. 
The explanation of Fritsch is more comprehensive and more plausible. 
According to this author a repeated displacement of the soft parts upon the 
bone within the loose subperiosteal tissue layer, complete enough to cause 
not only torsion of the vessels but also their rupture, is responsible. Such 
displacements result when the head of the child lies firmly against the wall 
of the maternal birth canal but is nevertheless movable to the extent that it 
is forced forward during the pain and in the succeeding pause again recedes. 
This latter factor is of special importance as the scalp may be secured in its 
original position by adhesion at some point of the maternal soft parts. 
According to Lange this change is particularly favored by the second and 
third phases of the mechanism of birth, the anterior rotation of the occiput. 
In the same manner, with the descent of the head a displacement of the bones 
may occur by a firmer adherence of certain portions of the scalp than of 
others to the maternal soft parts, whereby a cephalhematoma originates. 
By this explanation statistical findings, according to which cephalhematoma 



40 DISEASES OF THE MOW-BORN IN THE FIRST DAYS OF LIFE 

is most common upon the anterior parietal bone in head presentation and 
upon the occipital bone in breech presentation, are readily comprehensible. 
Its rarity with a narrow pelvis is explained, on the one hand, by the limita- 
tion or hindrance of these periodic to-and-fro movements, due to the dis- 
proportion between head and pelvis; on the other hand when a loosening of 
the scalp does exceptionally occur there is a possibility that owing to the 
continued compression of the infant's head the injured vessels become throm- 
botic even before the birth is terminated, and thus an effusion of blood is 
prevented. A second cause of development, no less important than the me- 
chanical, is also probably the result of circulatory disturbances such as are 
produced by an asphyxia sub partu. The venous vessels of the head and 
therefore of the bones are completely filled and tend more readily to rupture. 
Although the exit of blood is primarily aided in this manner nevertheless by 
a surcharge of carbonic acid its chemism is altered, in consequence of which 
it remains fluid, as is usually the case in cephalhematoma, instead of coagu- 
lating ( Spiegelberg, Ahlfeld). 

The cephalhematoma occurs as a tumor the size of a nut, apple, or fist, 
distinctly fluctuating, at first tense, later somewhat undulatory, painless, 
never passing beyond the limits of a suture or a fontanelle. This last pecu- 
liarity is due to its subperiosteal location, the periosteum being firmly adher- 
ent to the lateral margins of the bones. Cephalhematoma occurs in not 
quite 0.5 per cent, of the births. The bone most frequently affected is the 
parietal, and next in order of frequency are the occipital, frontal, and tem- 
poral bones. The condition is usually limited to one bone, but two, three, 
or, as was observed by Schroeder, even four may be involved. If both 
parietal bones are involved the suture lying between is retained for the reason 
previously mentioned. Occasionally, directly after birth the cephalhematoma 
is covered by a simple edematous swelling affecting the pericranium and does 
not become noticeable until the second or third day, after absorption has 
taken place. In cases of this kind the cutaneous covering is at first immotile 
and cannot be raised in folds until later. In other instances the effusion of 
blood, notwithstanding the necessary preparations for it have occurred intra 
partum, may not appear until after birth. The tumor is usually at first of 
moderate size but subsequently enlarges. This may continue to the end 
of the first week. Aitev a brief stationary period a gradual decrease occurs 
which occupies on an average from ten to fifteen weeks. This is accom- 
panied, according to the size of the tumor, by slight or distinct inflammatory 
swelling of the immediate surroundings. While from the periphery out- 
ward a concentrically progressive new bone formation gains more and more 
in space, the hemorrhagic fluid is gradually absorbed; the tumor becomes 
fluctuating and finally doughy. The soft bloody swelling, surrounded by 
a marginal bony ridge, then appears to the palpating finger like a depression 
in the roof of the skull. After absorption is complete a slight, uneven peri- 
ostosis remains for several months. This is the usual course. In larger 
cephalhematomata with slow subsequent healing there is sometimes the for- 



TRAUMA DURING BIRTH 41 

mation of a continuous osseous lamella on the part of the displaced perios- 
teum, corresponding to the vault of the tumor, the condition making itself 
noticeable by a parchment-like crackling of the surface. The tumor itself 
and the further process of healing are without effect upon the general con- 
dition of the child. Only with very decided extension, as would arise from 
a varied etiology, would a certain degree of anemia be present. Sponta- 
neous suppuration is exceedingly rare and usually occurs in connection with 
a simultaneous superficial injury to the skin, which for this reason must be 
kept particularly clean. In this connection the development of an eczema- 
tous disease of the head is serious. Therefore cleanliness with mild prophy- 
lactic treatment of the surface with inunctions is the only therapy which 
appears necessary. Operative removal of the cephalhematoma by division 
or by puncture with or without aspiration, is strictly contraindicated in un- 
complicated cases. Apart from the danger of infection with its serious 
consequences a secondary hemorrhage and renewed filling, especially at this 
stage, is not unusual. In the new-born a special pressure bandage cannot 
be utilized to prevent this on account of the ready compressibility of the 
skull. At the present time, therefore, the usual treatment of uncomplicated 
cephalhematoma is expectant. Eunge mentions that with an exceedingly 
large tumor which has existed for weeks puncture with succeeding aspiration 
may be indicated on account of the danger of bone necrosis, but expressly 
adds that incision is not absolutely necessary even in these cases until sup- 
puration appears. The latter condition, which may be recognized by red- 
dening of the skin, elevation of temperature and the constitutional disturb- 
ance, is the only indication for an immediate operation, which is then best 
accomplished by broad division. 1 

Associated with external cephalhematoma there may exceptionally be a 
corresponding subdural, therefore an intracranial, extravasation of blood on 
the inner surface of the bone of the skull affected. This occurs most fre- 
quently after injuries to the bone which have led to a bilateral hemorrhage. 
Otherwise only congenital split-like defects of ossification are the cause, such 
as often occur at the points of preference of the cephalhematoma — within 
the parietal bone and on the tabular part of the occipital bone — and are 
regarded as typical. The external hemorrhage then simply passes to the 
inner surface of the skull. Important in the recognition of this complica- 
tion is the possible presence of cerebral symptoms which are always absent 
in simple cephalhematoma. These, however, are found only in large sub- 
dural effusions of blood and consist of retardation of the pulse, superficial 
respiration, and sopor, which very soon terminate lethally. The smaller 
subdural hemorrhages, which are the usual type, generally run their course 
without symptoms. A further aid in diagnosis, according to the observation 
of Kirmisson, is the occasional distinct conduction of cerebral pulsation to 
the external surface of the cephalhematoma which, however, is only possible 

1 Antiseptic after-treatment is not easily accomplished. In most cases a very small 
incision or puncture followed by a dry cup (or a Bier suction) is appropriate. — Editok. 



42 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

with broad congenital defects in the bone and particularly in their imme- 
diate vicinity. 

Much more important to the life of the child than the previously men- 
tioned lesions are injuries of the cranial bones. They result primarily from 
the rapid entrance of the infantile head into the narrow inlet of the pelvis, 
either spontaneously, as the result of great exertion of the maternal abdo- 
minal press, or artificially, by pressure upon the abdomen, extraction at the 
pelvic extremity, or with the aid of forceps. According to the degree with 
which the projecting promontory occludes the entrance to the pelvis groove- 
like or funnel-shaped depressions arise. The former, which is the more 
common of the two, usually involves the anterior border of the parietal bone 
and lies during labor posteriorly and parallel with the coronal suture. 
Usually there is only a simple slight indentation, rarely a deep infraction. 
The prognosis of these changes in themselves is good. Infraction merely 
affects the external lamella of bone. Larger vessels are not involved. At 
most there may be a slight external subperiosteal hematoma (cephalhema- 
toma). This deformity becomes dangerous to life, on the one hand, with a 
simultaneous fracture or splitting of the bone in consequence of the eventual 
rupture of larger branches of the meningeal artery, on the other by the not 
infrequent complication of a simultaneous stretching or rupture of the 
squamous suture, which causes an injury to the transverse sinus. 

The funnel-shaped or spoon-like depressions are observed most frequently 
upon the parietal bone, which lies posteriorly during birth, and correspond 
with the parietal protuberance or the region of the coronal suture ; less often 
they are situated more anteriorly upon the frontal bone. Their greater 
depth is the reason that the depression of the external lamella has a greater 
extent and more readily gives rise to the development of a subperiosteal 
hematoma. With simultaneous penetrating fractures of bone or splinter 
fractures, especially in the temporal region, this deformity becomes serious 
on account of the ready injury to the larger vessels. The seriousness of the 
prognosis is based upon the frequent association of this complication as is 
proved by the statistical reports of these injuries. One-half of these chil- 
dren are still-born or die soon after birth. In those that survive a direct 
influence of the osseous impression upon the central organ itself has not 
been demonstrated. In time a gradual flattening of the funnel-shaped de- 
pression takes place. Complete adjustment, however, does not usually occur 
of itself; on the contrary, even after years a flattening or depression of the 
affected side of the head can be demonstrated. Of this fact I was able to 
convince myself in the children of a laborer's wife. The oldest, a boy of 
seven, showed a distinct lateral flattening of the head. Derangements were 
not present in this case nor in the other children; the mental activity of the 
older child particularly left nothing to be desired; he was one of the bright- 
est pupils of his class. 

For the treatment of these conditions an operative reposition of the dis- 
located bones, or, with penetrating fractures and splinter fractures, their 



TRAUMA DURING BIRTH 43 

partial removal has been proposed. In that class of cases which, as sta- 
tistics show, are not only at first but later without symptoms there is abso- 
lutely no necessity for such an exceedingly dangerous procedure. Only the 
presence of cerebral symptoms call for such measures. But even then an im- 
provement in the prognosis can scarcely be expected on account of the slight 
resistance which even strong and normally developed infants present to 
operation, and for the reason that in the given case there is in addition a 
decrease in energy and capability. Xor have I seen any essential success 
from the employment of an air-pump to raise the dislocated bone. 
Primarily the difficulty of an entirely air-tight closure of the surroundings ! 
The bell of the air-pump must be manufactured to conform to the shape 
and size of the head. In the meantime the fate of the child has been de- 
cided: Either it has succumbed to a circumscribed intracranial extravasa- 
tion of blood and the resulting increased pressure of the brain, or it is alive 
and recovering. In the latter case a further absorption of the hematoma 
is to be expected. Finally, the cohesion of the fractured bone lamella may 
require such strength on the part of the air-pump as cannot be considered 
immaterial to the life of a child in this condition. 

Rupture of the squamous suture, already mentioned in the discussion 
of the groove-like osseous depressions, may be observed alone, without this 
association. According to Fritsch there is a certain amount of tension and 
loosening of the suture with every difficult extraction at the outlet of the 
pelvis. As a matter of fact, so long as the skull is retained within the lesser 
pelvic entrance any decided traction upon the trunk acts in this manner 
upon that portion of the skull situated below the plane of the pelvic inlet. 
Thus the extraction of the succeeding head principally predisposes to this 
injury, much less that of the preceding head by the forceps. Otherwise the 
scarcely palpable portion of the squamous suture lying between the parietal 
and temporal benes is greatly broadened. More rarely there is a displace- 
ment of the margins of the bones, the parietal bone being forced toward the 
squamous portion of the temporal bone. The principal danger of this in- 
jury lies in a rupture of the transverse sinus, which, as is well known, is 
situated under the posterior portion of this suture. Aside from the severity 
of the venous hemorrhage the proximity of the source of hemorrhage to the 
base of the brain is unfavorable. 

Of the lesions at the base of the skull the separation of the tabular portion 
of the occipital bone from its condyloid part is typical. This arises most 
frequently with extraction of the succeeding head, more rarely with the pre- 
senting head, and exceptionally in spontaneous labor. Olshausen regards 
the transverse compression of the tabular portion of the occipital bone as 
principally responsible, Fritsch the greater tugging upon the trunk, a partial 
separation of the suture being caused by the tugging alone or in conjunction 
with the strong forcing of the tabular portion of the occipital bone under- 
neath the parietal bone, such as takes place from simultaneous narrowing of 
the inlet of the pelvis in its transverse diameter. The most serious conse- 



44 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

quence of this separation is the injury to the many contiguous vessels, par- 
ticularly of the transverse sinus and its continuations. The proximity of 
the base of the brain and the medulla oblongata increases the danger de- 
cidedly. In addition, the loosened tabular portion of the occipital bone 
may be displaced anteriorly upon the inner surface of the condyloid part and 
compress the contents of the foramen magnum as well as the portions of the 
spinal cord and medulla directly above. Although, as Fritsch correctly em- 
phasizes, a direct compression of the spinal cord can scarcely occur since it 
fills only a small portion of the canal, nevertheless a simple transitory com- 
pression may be sufficient for a fatal termination when it occurs with the 
needful strength such as is contributed by the amount of traction necessary 
in a constricted pelvis. 

In addition to these typical lesions of the skull, difficult birth of the 
presenting and succeeding head may lead to other manifold injuries: of the 
bone, from simple fracture to complete destruction; of the sutures, from 
simple distention to complete separation. The employment of the forceps 
is often a further occasion of too great compression. The direct effect of this 
pressure is always localized on the occipital and frontal bones, that of the 
promontory laterally upon the parietal bones or upon the frontal bone. In 
extraction at the pelvic extremity the latter arrangement is usual. The more 
the injury of the bone is located at the height of the skull the less is it im- 
portant; it becomes the more serious the farther it is below the plane of 
the parietal protuberance. The principal danger is injury to the vessels and 
the resulting intracranial hemorrhage. Separation of the sutures invariably 
results in injury of the sinus, and not only the transverse sinus at the squam- 
ous suture but also the longitudinal sinus at the frontal and saggital sutures 
may be involved. 

Intracranial hemorrhages have also been observed in spontaneous and 
even easy and rapid labors without injury to the skull. Here also the chief 
active factor is compression of the skull during birth, either by the pelvis 
or by the maternal soft parts. This alone may lead to such sequels with 
great displacement of the cranial bones. In this manner, in addition to 
tearing of the subdural vessels rupture of a sinus may occur. As the parietal 
and frontal bones are especially exposed to great displacement the longitu- 
dinal sinus is particularly affected. The superficial, dense mass of tissue 
sustains the pressure longer, while the weaker wall of the sinus yields. Ex- 
ternally the position of the bones post partum appears normal. Olshausen 
was the first to call attention to the occurrence of this injury also in spon- 
taneous labor. Naturally such a lesion of the sinus is fatal. In the cranial 
compression a simultaneous stasis of blood in the interior of the skull con- 
stitutes more than an occasional aid. The vessels are incapable of depleting 
themselves of blood as rapidly as is required by the external pressure. Com- 
pletely filled they tear more readily. Such intracranial stasis is most fre- 
quently the result of asphyxia but may be due to mechanical compression of 
the vessels of the neck, especially of the veins. Kiistner observed intra- 



TRAUMA DURING BIRTH 45 

cranial hemorrhages in congenital goiter, and repeatedly when the umbilical 
cord was wound firmly around the neck. Thus the greater predisposition 
of premature children is explained. While, on the one hand, the condition 
which leads to an interruption of pregnancy may produce a disturbance of 
the intrauterine respiration, on the other hand the skull of the premature 
infant is softer and more yielding and therefore is readily compressed by a 
feebler force, the walls of its vessels being less resistant. The seat of these 
intracranial hemorrhages is usually subdural or subarachnoid and corresponds 
most frequently to the convexity, more rarely to the base of the brain. Hemor- 
rhage into the substance of the brain is rarely observed. Finally, there are 
reports of hemorrhage into the ventricles which cause a suspicion of special 
stasis and compression in the region of the veins of Galen (Kundrath). 

In regard to the symptomatology of intracranial hemorrhages, either of 
spontaneous or traumatic origin, the statement is true that hemorrhages of 
the convexity within certain limits give rise to decidedly fewer phenomena 
than those at the base of the brain, and the more so the farther they are 
situated from the surface. Hence, in conformity with the localization of 
the hemorrhages occurring spontaneously and for the reason that the lighter 
grades appear to predominate, as a rule no symptoms are present. When 
they do arise in consequence of a greater hemorrhage or of a hematoma in 
the cerebrum they first consist of a retardation of the pulse, superficial res- 
piration, and sopor. For a differentiation from simple asphyxia, and in the 
absence of external .injury to the skull, an occasional more marked promi- 
nence of the fontanelles is of value. This observation is all the more im- 
portant as, with intracranial hemorrhages any great corporeal shock, and 
therefore Schulze's swings, is contraindicated and a less dangerous and 
milder method is advisable, for example that proposed by Schroeder. With 
a basal or massive hemorrhage the soporous condition soon terminates fatally. 
With smaller hemorrhages in the region of the convexity the severe symptoms 
may gradually disappear and recovery ensue, or, especially with a subarach- 
noid or cerebral localization, there may be corresponding focal phenomena: 
hemiplegia, convulsions. In cases of this kind with hemorrhage at the base 
of the brain paralyses of the oculomotor, trochlearis, and abducens nerves 
appear and occasionally also paralysis of the facial nerve. Their prognosis 
is at first doubtful, but they tend to recover. That even these have in time 
improved and finally terminated in recovery is not especially exceptional. 
As is the case in all intracranial hemorrhages, there is danger of the develop- 
ment of a pachymeningitis which may eventually lead to a renewed hemor- 
rhage (Dohle). 

Traumatic injury of the skull and brain intra partum is looked 
upon by psychiatrists as an important etiologic factor in the later develop- 
ment of certain mental and nervous diseases: epilepsy, chorea, athetosis, 
spastic contractures, spastic paralysis, imbecility, idiocy. In several com- 
munications the artificial termination as well as the protracted duration of a 
labor have been mentioned as having a decided influence upon eventual 



46 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

serious sequels. Asphyxia also plays an important role. In two cases of 
severe asphyxia B. Schulze noted idiocy later. The course and especially 
the increase of the condition and its long duration rather favor a simulta- 
neous intracranial hemorrhage. The great percentage of histories of ab- 
normally prolonged labors with operative termination gives cause for much 
thought. However, the relatives in general are inclined to greatly exagger- 
ate the difficulty of a labor. This number, which is nevertheless small, 
is opposed by a large series of carefully observed cases in which, even after 
severe injury, complete recovery and subsequent normal development con- 
tinued for a number of years. Although it cannot be denied that a later 
occurrence of these conditions is possible, they must certainly be exceptional. 1 
Among the nerve lesions of the head paresis of the facial nerve after 
forceps delivery has been mentioned. This occurs most frequently when the 
head is grasped obliquely, as the application of the forceps upon or behind 
the ear presses the trunk of the nerve at its exit from the stylomastoid foramen. 
Such traumatic facial paralysis is not a rare complication after forceps de- 

1 The author underrates the frequency of the bad results both of asphyxia and of 
hemorrhages. The latter, besides the causes described in the text, are anatomically pre- 
determined by the insufficient structure of the tissue of the blood vessel walls of the 
new-born and the shallowness of the impressions digitatae of the inner layer of the skull. 

The progress of asphyxia and of its treatment is a very doubtful one in many 
cases. It depends not only on the knowledge and skill of the physician (" obstet- 
rician"), but on the causes of the abnormal condition. A moderate or serious com- 
pression of the head, compression or prolapse of the cord, intrauterine or intravaginal 
respiration and aspiration of foreign bodies (amniotic liquor, blood, meconium), apo- 
plexy, anemia of the fetus, accumulation of carbonic acid in the blood, poisoning by 
chloral or morphine taken by the mother, or by her excessive temperature, congenital 
diseases and malformations, each of them, or several combined, influence both the 
prognosis of the individual case and the results of therapeutic procedures. 

When the long duration of labor, the prolapse of the cord, the protracted compres- 
sion of the head, the early loss of amniotic liquor, placenta prsevia, or a high tempera- 
ture of the mother endangers the life of the fetus, the best preventive of asphyxia is 
the artificial termination of parturition. (Comp. Jacobi, Therap. of Inf. and Childhood, 
3. ed., p. 81.) 

Extravasation or thrombosis during a long, or even a brief, asphyxia is the cause 
of secondary meningitis or encephalitis with its results. Even without meningitis they 
lead to paralysis, total or partial, idiocy, or epilepsy. The two latter are often com- 
bined. Many hundreds of such cases depending on aspyhxia have been observed by me, 
as even the attendants on my clinics in the last fifty years may testify. When I 
ask: Did the baby cry when born? Did the baby live? The unsuggested reply is that 
it took minutes, took a long time for the attendant, the midwife, the doctor, to bring 
the baby to life; that the baby did not behave, did not cry, did not smile, did not 
notice like other babies, and had slight, or general, or local convulsions. That is why 
I have impressed upon my hearers the necessity of attending to the baby first, and 
— unless there be a rare urgency — the mother afterwards. 

Intracranial hemorrhages are more dangerous in the newly born than they are even 
in advanced age in which arteriosclerosis is common. For in the newborn and young 
infant the blood is less coagulable than later, and the extravasation more copious on 
that account. That is why so many babies die of intracranial hemorrhage in the first 
week of their lives; and why every convulsion, and every severe attack of whooping 
cough in the very young may prove fatal, or — what is more pitiful — the cause of hemi- 
plegia, paralysis, epilepsy, idiocy. — Editoe. 



TRAUMA DURING BIRTH 47 

livery, which appears to occupy a first place among the etiologic factors. This 
condition is also noted exceptionally after spontaneous labor. Upon extrac- 
tion of the descending head the peripheral portion of the nerve is not exposed 
to direct pressure. Marked protrusion of bones in the pelvic inlet, either the 
promontory or the symphysis, begins higher. Depressions of the bone, di- 
rectly or indirectly the result of a simultaneous intracranial hemorrhage, may 
have a damaging effect upon the center of the facial nerve. The immediate 
proximity of centers for the arm and leg, as well as that of the hypoglossal 
nerve, makes their involvement, immediate or transitory, unavoidable on 
account of collateral edema. A damage of the facial nerve center may also 
occur in spontaneous head presentation through injury to the bone (Schutze). 
In addition, with a flat pelvis the protracted labor adds to the danger of pres- 
sure necrosis of the scalp, and the consecutive swelling in the vicinity, pro- 
vided it be not too remote from the stylomastoid foramen, may damage the 
peripheral portion of the facial nerve (Knappe). Another important etiologic 
factor in spontaneous head presentation in a flat pelvis is furnished by the 
presence of exostosis of the symphysis. Well-developed anterior parietal bone 
presentation permits this bony process, similar to the apex of the forceps, to 
act directly upon the nerve trunk after its exit from the skull. Vogel reports 
two cases of this kind. In his opinion the observation of Ludwig may be 
explained in the same manner. This author, however, although uncertain 
whether the method of development is peripheral or central, believes that the 
latter is not unlikely. Vogel's contrary opinion that the period of recovery 
was too short (three to five days) will probably have to be admitted. Finally, 
there is a fourth report of facial paralysis in anterior parietal presentation 
with markedly pendulous belly (Frank), which is referred to strong pressure 
of the shoulders against the aural region. A hematoma of the sternocleido- 
mastoid at its insertion in the skull as a cause of facial paralysis has been 
mentioned. B. Schulze, to whom we owe this observation, refers the develop- 
ment of the hemorrhage to a strong hyper-rotation of the shoulders after the 
birth of the head. Recovery occurred in four or five weeks simultaneously 
with absorption of the hematoma. In the discussion of this report Olshausen 
pointed to the influence of amniotic strands in the sense of a tugging at the 
affected area. Geyl thus attempts to explain a case observed by him, without, 
however, giving positive objective reasons. 

Corresponding to the usual nature and the place of development paresis 
of the facial nerve is unilateral in by far the majority of cases, and shows 
itself clinically in a disturbance of function of the facial muscles supplied 
by it which is especially obvious when the infant cries. The affected side 
remains flaccid and immotile; the healthy side, in contrast, shows a marked 
deviation. The mouth and nose are drawn toward the normal side. The 
nasolabial fold, more prominent on the unaffected side, has disappeared upon 
the paralyzed side. The eye upon the affected side remains open (lagoph- 
thalmus). Usually the entire trunk of the pes anserinus major is affected, 
more rarely only a portion and then the lower, which supplies the nose and 



48 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

mouth. The prognosis of this unilateral peripheral facial paralysis is always 
favorable. As a rule the affection disappears within a few days. This rapid 
improvement sometimes refers only to the upper branches (eyes) while 
recovery of the branches of the mouth takes place more slowly and is not 
completed before two or four weeks. In a few cases entire lack of improve- 
ment and persistence in later life has been noted (Duchenne, Henoch, Selig- 
miiller, etc.). This naturally presupposes a severe labor with total destruc- 
tion of the nerve. In the differentiation of this purely peripheral nerve lesion 
beyond the stylomastoid foramen from the intracranial or basal form the 
condition of the superficial petrossal nerve, that is, the velum of the palate, 
upon the affected side is important. It is true, the normal condition of the 
latter will be a more positive warrant that the lesion has occurred peripherally 
from this branch. The inverse condition we will rarely have opportunity to 
demonstrate in the new-born. Basal facial paralysis is usually due to a basal 
injury of bone and intracranial hemorrhage, which on account of their posi- 
tion and their contiguity to the medulla oblongata at once give rise to severe 
cerebral symptoms. 1 The same is true of bilateral facial paralysis, singly or 
with involvement of the ocular muscles. The limitation to the nerve alone 
is scarcely likely on account of the smallness of the space. That for this 
reason the prognosis of these intracranial nerve lesions usually offers but little 
hope of recovery need scarcely be remarked. The estimation of injuries of 
the facial nerve center is according to the same fundamental laws as have 
already been detailed of cerebral lesions in general. Simple peripheral nerve 
paralysis alone is influenced by treatment. This, however, is rarely necessary 
on account of the usually rapid spontaneous cure. Only in those cases which 
show no improvement in the second week is faradization indicated. For 
similar reasons the prolongation of the lagophthalmus exceptionally may 
require corresponding protective measures for the eye. Finally, a hindrance 
of nourishment through difficulty in sucking is possible. This only occurs 
with a severe disturbance, and then when the child is fed at the breast. I 
have never come across a case of this kind. Under such circumstances the 
bottle will be a serviceable substitute. 

Other injuries to the face are rare. In face presentation a careless and 
rough examination may be an accidental cause. Otherwise pressure of the 
forceps is the most important factor. In a narrow pelvis the forceps 
applied to the head, which is still high, occupies the transverse diameter. 
One blade of the instrument lies more or less across the face. In this 
way the nose may be injured and fracture of the nasal hone may result. 
Olshausen saw this injury after a spontaneous labor. The possible lesion of 
the upper eyelid by the forceps has already been mentioned. Prophylactically, 
it is advisable even in a severe labor to avoid too great compression of the 
handle of the forceps. In the Mauriceau or Veit-Smellie maneuver the mouth 
and oral cavity are the points of attack. The introduction of two fingers 
may tear the angle of the mouth ; great pressure upon the floor of the mouth 
1 See " Diseases of the Nervous System," p. 674, et seq. 



TRAUMA DURING BIRTH 49 

may cause suggillation, compression, or a lesion of the soft parts situated 
there; finally, too strong tugging upon the lower jaw may cause its fracture 
or complete separation. Therefore, careful management and manipulation 
of this method in the living child is absolutely necessary. 

In the neck superficial injuries of the skin upon the anterior side in the 
form of transverse distention streaks are familiar in face presentation. They 
are due to great tension of the skin. Kaltenbach also saw these lesions upon 
the nape of the neck in natural occiput presentations. Fat children appear 
to be particularly predisposed to the latter. Recovery occurs spontaneously 
within a few days. When the injuries are of decided extent a treatment with 
salves may be necessary. Deeper injuries to the soft parts occur principally 
under the typical picture of a subcutaneous hematoma on account of the pre- 
dominant torsion of the muscles. They have been observed after artificial 
as well as spontaneous head and breech presentations and occur most com- 
monly in the sternocleidomastoid muscle, more rarely in the trapezius or the 
scaleni, and exceptionally in the latter muscles alone. The hematoma is 
situated laterally and, according to the region and cause of its development, 
near the head or in the vicinity of the shoulder. As a rule it is unilateral, but 
a bilateral development has been observed. After a spontaneous labor, as a 
rule, its extent is slight, not greater than the size of a cherry; the more 
marked grades are usually the result of operative termination of the labor. 
We owe to Kustner the investigation and proof of the various origins of these 
injuries as well as the active mechanism, particularly as by this means we 
have obtained important indication for prophylaxis when operation is neces- 
sary. According to this author a small number owe their development to 
direct force. This may occur with the forceps by the greater pressure of one 
blade, as well as in a breech presentation by extraction with the finger placed 
over the nape of the neck and laterally to the neck. In the majority of cases 
the injury is caused indirectly by immoderate distention. This may happen 
to the trapezius muscle and to the scaleni by tugging in the longitudinal axis 
of the child. The same lesion to the sternocleidomastoid is possible by ex- 
treme rotation of the head, whereby the inactive muscle, on the side to which 
the face is directed, is stretched. The isolated hematoma of the sternocleido- 
mastoid is most distinct after spontaneous delivery, when there has been no dis- 
turbance from tugging in the logitudinal axis. Here the retention of the shoul- 
ders is especially serious as the head, which is at the exit of the pelvis, lies with 
its breadth in the broad pelvic diameter. A similar inverse mcehanism may 
occur in spontaneous breech presentation. If, in spontaneous delivery, the 
active natural effort is sufficient for the laceration of a muscle, as Kiistner's in- 
vestigations indicate, such an accident is all the more likely in an artificial 
rotation of the head by the forceps, or of the shoulders in a breech presenta- 
tion. If in this rotation the tugging occurs in the longitudinal axis of the 
child the injury correspondingly may show a wider distribution to the splenii 
and to the trapezius muscles. The prognosis of this injury to the soft parts 
(as regards life) is always good, and is generally favorable as regards func- 



50 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

tion. According to Kiistner even large hematomata disappear spontaneously 
in four to eight weeks. The same is also true of paresis of the muscles of 
the shoulder and arm which is sometimes present simultaneously and for 
which Fritsch considers the direct pressure on the nerve by the finger of 
the obstetrician or the compression by the hemorrhage as responsible. Stroh- 
meyer's view that tearing of the sternocleidomastoid readily produces a myo- 
genic contracture — a caput obstipum — has been corrected by Peterson; 
accordingly we must regard this sequel as at most very exceptional. Small 
and even medium-sized hematomata heal without leaving a trace. Only with 
a large effusion of blood may it be advisable to prevent a possible residuum by 
the appliance of a proper bandage and afterwards by mild massage and pas- 
sive movements. 

Extensive injuries to the soft parts of the neck are usually combined with 
injuries to vital organs, especially of the skull and brain. When these are 
absent the simultaneous nerve injury makes a return of movement very ques- 
tionable. Paralyses of this origin are characterized by atrophy of the muscu- 
lar area which develops within a few days. 

The employment of extreme force at the shoulders in a breech presenta- 
tion or on the descending head in head presentation may also endanger the 
vertebral column. This structure is well protected by its powerful ligamentous 
apparatus to sustain an energetic tugging so long as this occurs in the direc- 
tion of its longitudinal axis. Deviation to one or both sides may be serious. 
Epiphyseal rupture, hemorrhage into the spinal cord canal, tearing or sepa- 
ration of the spinal cord or of the nerves originating here are easily the 
consequences. Whether hemorrhages may occur in the spinal cord canal after 
delivery by simple tension, without direct injury to the bone, has not yet 
been proven. Practical experience is opposed to this, according to which 
later disturbances are exceptional. Neuropathologists, however, have recently 
taken the view that they play an important role in the etiology of subsequent 
diseases of the spinal cord. 

In the region of the thorax injuries to the lungs may occur, as in adults, 
from fractured ribs and exceptionally from a fractured clavicle. But even 
without such injury hemorrhage into the pleural cavity has been noted. The 
cause was then usually based on the tearing of over-full venous nets of many 
branches, situated upon the anterior side of the vertebral column, particularly 
in asphyxiated new-born. 

The organs of the abdominal cavity are especially exposed to damage by 
an improper or unskillful delivery in breech presentations : when the abdomen 
is grasped firmly and roughly either in extraction or in raising the trunk to 
free the arms. Such injuries are also reported in difficult labor associated 
with great tugging and distention of the trunk : rupture of the liver or spleen, 
hematoma of the adrenals, fatal hemorrhage into the abdominal cavity. In 
view of the fact that in these cases asphyxia was present it is uncertain how 
many of these sequels were due to this cause. 

Birth trauma of the extremities results in injuries to the bone (infraction, 



TRAUMA DURING BIRTH 51 

fracture, epiphyseal separation) and paralysis of the nerves, alone or in asso- 
ciation. Before entering upon a description of the bone lesions it may be 
advisable to devote a few words to the so-called intrauterine fractures. Until 
recently certain single angular bendings of the tubular bones, presenting 
great similarity to dislocation, healed fractures, and infractions, were thus 
incorrectly designated. They are observed most commonly in the lower leg, 
rarely in the forearm, and exceptionally in the clavicle. Bony deposits or 
thickenings in the vicinity of the inflexion were regarded as residues of an 
excessive callus formation, and slight cicatricial cutaneous changes in this 
region as injuries of the skin caused by the fractured ends. .This conception 
of an intrauterine origin of fracture of bone, which occasionally was sup- 
ported by the statement of the mother of a trauma during pregnancy, was a 
more welcome and unobjectionable explanation. Where such an accident 
was not admitted no question was raised, as the power of the contracting 
uterus during pregnancy was considered responsible. Recent investigations 
(Max Sperling, Haudeck, Burmeister, etc.) have shown that these deformi- 
ties are not the consequence of an intrauterine traumatic bone injury; on 
the contrary, they are simple disturbances of development. In the prepara- 
tions examined there was no trace, macroscopically or microscopically, of a 
total or partial interruption of continuity. In the axis the bony substance 
was unchanged and uninterrupted. Xothing in the nature of a fracture 
cicatrix or of a change which could be regarded as such could be seen. The 
periosteal covering also, except for a slight annual distribution of its numer- 
ous cells corresponding to the point of inflexion, was unaltered. The osseous 
thickening, regarded as callus formation, proved to be a simple, osteoplastic, 
subperiosteal callus which was usually more strongly developed on the con- 
cave side of the inflexion and here caused a certain compensation of the 
angle. Finally, the skin was entirely normal with the exception of the 
cicatricial retractions which showed a flattening of the corium papillae and 
a thickening of the lower layers of the epidermis. No signs of cicatricial 
tissue were ever present If the view of a simple inflexion and curvature of 
the tubular bones without any interruption of continuity was considered very 
likely at that time it has recently received confirmation by the Roentgen 
pictures of these deformities. The contour of the bones is perfectly uniform ; 
irregularites such as occur in the healing of dislocated tubular bones from 
an immoderate formation of callus are not observed. Marked angular in- 
flexion of the tubular bones without interruption of continuity can only occur 
at a very early period of fetal life, before ossification has begun, or at least 
before it is much advanced, therefore, according to embryologic investiga- 
tions, within the first two months. The defective development observed in 
60 per cent, of the cases makes it obvious that the beginning is prior to the 
completion or internal differentiation of the stump of the extremity. As a 
casual factor external trauma, notwithstanding the necessarily associated 
sequels (injury to the maternal soft parts, interruption of the pregnancy) 
must be rejected on account of its transitory effect. The same is also true 



52 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

of contractions of the uterus. Only the influence of prolonged limitation of 
space can be considered, either as it concerns the fetus as a whole (deficiency 
of amniotic fluid) or the restriction of individual portions of the body by 
amniotic strands and folds. A few authors regard tumors of the uterus 
(myomata), according to their situation, as responsible. The comparatively 
great frequency of an associated defective development makes it probable 
that the influence of amniotic strands is an important and common cause of 
these deformities also. Positive supportive criteria are furnished by the 
cicatricial cutaneous changes at the point of inflexion and remains of strands 
in the placenta^or upon the affected extremity. This is also the preferred 
explanation of the origin of periosteal osseous thickenings or of the localized 
periostitis which is the foundation of them, as well as of the defective 
development of the portion of the extremity situated peripherally from the 
point of inflexion. 

After excluding these solitary angular curvatures from the various 
spontaneous intrauterine fractures there still remain the exceptional occur- 
rences of ununited fractures of bones. Besides the atypical localization their 
multiple occurrence in the same child is characteristic. Complete interrup- 
tion of continuity is rare; usually there is only an infraction. The causes of 
this slight capability of resistance and ready tendency to break have been 
found macroscopically to be an abnormal formation of bone substance, defi- 
cient and irregular deposits of calcium, extraordinary increase and dilatation 
of the Haversian canals, and substitution of the spongiosa by a rich-celled 
connective tissue. These changes were formerly regarded as similar to those 
of true rickets, with which, however, the normal composition of the bony 
boundary of the epiphysis does not agree. The fundamental cause of this 
bone disease is still unknown. A general nutritive disturbance of the child 
or of the mother is usually invoked in explanation. According to some 
authors previous syphilis plays a decided role. It must also be remembered 
that specific luetic processes within the tubular bones result in a similar 
tendency to fracture. Naturally, such spontaneous fractures of bone occur 
most readily at birth, favored by a special position of the affected member. 
A few reports indicate an intrauterine origin. Their direct cause, whether 
from contraction of the uterus, from energetic movements of the child, etc., 
is entirely within the realm of hypothesis. 

With a normal physical development injuries of the bones of the ex- 
tremities are due principally to an operative termination of birth and are 
particularly common in extraction in breech presentation when the course is 
altogether abnormal or when obstinate conditions exist, such as contraction 
of the pelvis, resistance of the maternal soft parts, etc. Here also the regu- 
larity of the active factors creates a certain uniformity of the injuries and 
entirely justifies the designation of typical. In the upper extremity and its 
shoulder girdle fracture of the clavicle is most common. This may occur 
during the release of an arm and also in head presentation. Great limitation 
of space occasionally renders the first introduction of the hand serious, in 



TRAUMA DURING BIRTH 53 

that the shoulder and clavicle of the child arc immoderately compressed in 
their longitudinal diameter. In other cases this result during the release of 
the arm occurs through the agency of the upper arm, analogous to the pro- 
duction of fracture of the clavicle in the adult from a fall upon the extended 
limb. More rare than this indirect mechanism is a direct cause, a longitudinal 
compression having occurred by too great retraction of the shoulders in the 
maternal pelvis prior to the release of the arm, or in head presentation by 
the pressure of the finger upon the shoulder. iVccording to Kiistner too great 
pressure upon the shoulder as well as forced traction upon the arm may also 
exceptionally cause an epiphyseal separation of the sternal end of the clavicle. 
As a rule the ligamentous apparatus here offers such resistance that fracture 
of the bone takes place instead. The fracture of the clavicle, which is similar 
to the infractions of adult life, is usually at the boundary of the external and 
middle third of the bone, rarely in the middle. As a dislocation of the frac- 
tured ends is not usual the diagnosis is generally based upon the results of 
palpation: abnormal inflexion in the area concerned, decided pliability upon 
slight pressure, crepitation. Lower position of the affected shoulder and 
visible decrease in breadth of the corresponding half of the shoulder are only 
perceptible with marked deviation. Unless careful investigation is made 
the injury often remains undiscovered until the beginning of the second 
week, or until a perceptible callus formation directs attention to the condi- 
tion. Besides the scientific interest and the consideration for the child it 
is always advisable for personal reasons for the obstetrician after every labor 
to examine the child minutely for injuries and thus avoid unpleasant sur- 
prises and the resulting criticism on the part of the relatives. 

The prognosis of fracture of the clavicle is always favorable. Even if 
undiscovered and untreated it heals [mostly. — Editor] without sequels. Spe- 
cial treatment of simple infraction is quite unnecessary. With complete 
separation and consecutive dislocation of the fractured ends a light fixation 
of the arm to the wall of the thorax — which is protected by cotton — by means 
of a few turns of the bandage or of a triangular cloth is sufficient. The bath 
need not be denied the child if, as Fritsch advises, the bandage is not re- 
moved and is subsequently renewed. Especially anxious mothers may omit 
the bath and leave the bandage on until the end of the first week, when the 
callus which is usually palpable indicates the beginning of consolidation. In 
these cases the skin should be carefully anointed to prevent a possible de- 
velopment of eczema, and for the same reason a wetting of the bandage makes 
an immediate change imperative. 

Much more rare than these clavicular lesions are fractures of the humerus. 
This bone is particularly endangered in releasing the arm, especially when 
that member is turned upward or is bent behind the neck, and above all 
when it is lodged between the head and the promontory or symphysis. The 
most common accident is, fracture of the diaphysis and epiphyseal separation 
near the head of the humerus. The former presupposes that the force of 
the trauma has occurred near the middle of the diaphysis. Besides the amount 



54 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

of strength used ilio smallness of the point of attack plays an essential role. 

The release of the arm by one finger is therefore more dangerous than if 
several fingers were employed. Usually the first symptom that is conspicuous 
is a hindrance of function. The injured arm remains immotile. The fingers 
alone, particularly their flexion, are less implicated. Diagnostically, in addi- 
tion to the greater passive movability at the abnormal area the crepitation 
which is perceptible here is conclusive. Furthermore the child always screams 
when the affected extremity is moved and particularly the ends of the frac- 
ture. Formerly it was necessary to depend alone upon these objective phe- 
nomena and because of the smallness of the diaphysis errors were quite com- 
mon; the last few years, however, have furnished an absolutely positive 
criterion in the X-ray picture. This should be utilized not only in doubtful 
but also in perfectly obvious cases since by this means the nature and position 
of the fracture can be accurately determined. 

The prognosis of fracture of the humerus in the new-born cannot be re- 
garded as unfavorable. Although it is not always possible entirely to exclude 
deformity, the resulting disturbances are exceedingly rare. As to treatment, 
the reposition is usually easy but the retention exceedingly difficult. A bandage 
too tightly applied may be the cause of muscular atrophy. A loose bandage 
has no influence upon the dislocation. It is difficult to find the correct alter- 
native between these two extremes. Fritsch merely ties the upper arm at 
a right angle with the thorax and has this bandage renewed after every bath. 
The moderate mobility of the fingers and hand which remains prevents later 
contractures. A dislocation even then cannot be altogether avoided but the 
deleterious results, according to practical experience, are slight. Although 
every practitioner must regard this method of Fritsch as correct, neverthe- 
less he will do well, in the beginning at least, to omit the daily change of 
the bandage and the bath unless he desires to avoid the reproach of the rela- 
tives for negligence and other unpleasantness. However, the bandage must 
be controlled and renewed in three or four days at the latest and may be 
serviceably associated with the bath. It is also advisable to cover the upper 
arm as well as the thorax with a thin layer of cotton and previously to anoint 
the skin. In the application of bandages around the thorax it must always 
be remembered that the chest of the new-born is readily compressible and 
that very little pressure is required to constrict and hinder the respiration. 

In addition to the fixation bandage retention of the fractured ends may 
be accomplished by permanent extension. This treatment, and especially 
the method of Bardenheuer (Cologne) which has been tested in many cases, 
has given the best results, especially in fractures of early infancy. By pull- 
ing and opposed tugging the fragments may be easily and securely retained 
in their normal position. All atrophy from inactivity or pressure of the 
muscles is excluded. The skin of the newly born infant bears the necessary 
adhesive plaster bandage very well. Above all, with this method the nursing 
and care of the child are absolutely unhindered. The daily bath had better 
be omitted, but an occasional bath may be given notwithstanding the bandage 



TRAUMA DURING BIRTH 55 

as the subsequent readjustment of the entire apparatus is very much easier. 
Briefly, the employment of permanent extension in the cases in which dislo- 
cation occurs readily is to-day considered of particular advantage and furnishes 
the best results. 

Epiphyseal separation may occur in a manner similar to fracture of the 
diaphysis if the point of greatest force upon the humerus is close to its 
boundary of ossification. The best example is the hooking in the axillary 
cavity after the development of the head — during extraction of the trunk — 
when the arms are still placed laterally to the body. Also serious in this 
connection are all movements of the arm which appear to be opposed to the 
normal structure of the shoulder- joint : rotation about its longitudinal axis, 
movement of the arm over the back of the child and near the body. Kiistner 
has pointed out that the flat, only slightly concave formation of this marginal 
plane in the new-born decidedly favors the occurrence of injury. For a 
proper understanding of the sequels it must be remembered that in the new- 
born the epiphyseal boundary is external to the capsule of the joint and 
therefore, in such a separation, this structure may remain uninvolved. As 
in diaphyseal fracture, a hindrance of spontaneous movement first calls 
attention to the condition. Furthermore, the affected arm assumes a very 
characteristic, almost pathognomonic position, varying according as to whether 
there is merely a loosening of the epiphysis without injury of the periosteum 
or whether the latter structure also is injured and the diaphyseal end cor- 
respondingly dislocated. In the former case the damaged extremity shows 
a strong inward rotation of the upper arm, perhaps associated with hyper- 
pronation of the forearm. In the new-born all of the outward rotators are 
inserted at the epiphysis, their antagonists, with one exception (subscapu- 
laris), in the shaft of the diaphysis. With the separation of the bone the 
antagonistic action of both muscle-groups is destroyed and each may act 
independently of the other. The action of the outward rotators is limited 
to the epiphysis and remains concealed from the eye of the observer; that 
of the inward rotators comes into the position of the diaphysis and of the 
lower epiphysis united to it. The periosteum tears upon that side to which, 
on account of the force, the diaphyseal end has deviated. If the end slips 
back at once the condition is the same as in simple separation of the epiphysis 
without injury to the periosteum, therefore merely an inward rotation of 
the upper arm. If, however, the diaphysis remains dislocated the upper arm 
assumes a position similar to that of luxation. If the periosteal tear and 
dislocation affects the axillary side the longitudinal axis of the upper arm, 
as in an axillary and subcoracoid dislocation, deviates anteriorly and down- 
ward from the articular plane. If this condition has occurred on the external 
side the deviation is posterior. As the head of the joint in epiphyseal sepa- 
ration remains in the plane the corresponding flattening of the shoulder is 
absent and the curvature of the diseased member is exactly like that of the 
normal. Futher, in contrast to the objectively distinct, limited movability 
of the shoulder-joint after a dislocation, this movement appears to be par- 



5G DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

ticularly facilitated after an epiphyseal separation. Finally, traumatic lux- 
ation of the shoulder-joint in the new-born is absolutely impossible under 
normal circumstances on account of the slight resistive power of the epiphy- 
seal boundary. Only in very exceptional cases where the union of the joint 
has undergone a disturbance of development, or ossification of the diaphyseal 
and epiphyseal boundary has occurred intrauterine is such a condition pos- 
sible. According to Kiistner's careful analysis those cases of traumatic lux- 
ation in the new-born which are found among the earlier reports are erroneous. 

Diaphyseal rupture differs from epiphyseal tearing not only in the pathog- 
nomonic position but by the absence of distinctly palpable rough crepita- 
tion. As the separation occurs in the cartilaginous layer a soft, so-called 
cartilaginous, friction at most is noticeable. Naturally, in addition to the 
tear of the periosteum there may also be injury of the adjacent soft parts. 
This, however, is usually slight; large effusions of blood are rare. Involve- 
ment of the nerves is more common. Corresponding to the anatomical rela- 
tions of this region a dislocation of the diaphyseal end toward the axillary 
cavity is chiefly the cause of this condition. Not only the nearest nerve, the 
axillary, is endangered, but also the entire lower portion of the brachial 
plexus which innervates the arm. The condition is usually that of compres- 
sion, rarely of tear. Eventual sequels are at first concealed by the general 
immovability of the arm brought about by the trauma. Paralysis and muscu- 
lar atrophy do not arise until after consolidation has taken place. 

In the special diagnosis of epiphyseal separation in the new-born these 
clinical symptoms are of principal importance as the X-rays are of much less 
service here than in fracture of the diaphysis. The epiphyses are still 
cartilaginous and are penetrated by the rays the same as other soft parts 
and therefore cannot be distinguished skiagraphically. Nevertheless, an im- 
portant confirmation of the clinical findings may be indirectly obtained by 
exclusion. 

The prognosis as regards the use of the affected arm, aside from a pos- 
sible nerve paralysis, even after the correction of the dislocation is essentially 
dependent upon the careful prevention of an opposed rotation of the two 
fractured ends. If the latter condition is overlooked the epiphyses, rotated 
outwardly, will heal upon the reversely turned diaphysis and the movements 
of the arm will be much restricted or entirely impossible. Therapeutically, 
therefore, in a dislocated epiphyseal separation the correction of the deviation 
ad axin comes into question and can usually be brought about by simple traction 
of the arm. The second requirement, the relief of the dislocation at the 
periphery, can only be accomplished by bringing the diaphysis into a position 
which corresponds to the shorter end — a direct influencing of the epiphysis, 
which is inaccessible. With this outward rotation, even if it occurs some- 
what more posteriorly, the upper arm can only be fixed uncertainly and with 
difficulty to the thorax of the new-born. Kiistner therefore advises the 
employment of the forearm as a second splint : The upper arm, after rotation 
outward, is fastened to the strongly supinated forearm, which is flexed at an 



TRAUMA DURING BIRTH 57 

acute angle so that the hand lies upon the injured shoulder, and both are 
fixed to the thorax with an axillary pillow between. Preferable to this very 
difficult process is the employment of permanent extension, from which, 
(according to the reports of Jetter, Wolff, Linser, and others) in the treat- 
ment of this injury particularly, the most positive results are obtained. 
Operative procedure — direct fixation of the epiphysis to the diaphysis by a 
steel punch (Helferich) which until recently was regarded as the only sure 
method — can only come under consideration when simple reposition is pre- 
vented by compression of soft parts (button-hole tear in the periosteum), 
which in the new-born is exceedingly unusual. 

Other injuries of hones of the shoulder-girdle — epiphyseal separation at 
the collum scapulae, separation of the acromion, transverse fracture of the 
scapula, and epiphyseal tear at the lower end of the humerus — are so rare 
that their discussion may be omitted. 

Thus far only such paralyses of the arm have been considered as develop 
in consequence of central lesions of the brain and of the spinal cord or 
immediately after injuries to the bone. Cerebral localization requires, apart 
from a simultaneous disturbance of the general condition, a more or less 
distinct involvement of other neighboring focal areas and affects at least 
the entire upper extremity just as in the myelogenous form. In contrast 
thereto, in a peripheral secondary injury to the brachial plexus, on the one 
hand, the paralysis is incomplete, that is, certain parts, usually the hands 
and fingers, are still capable of motion; on the other hand, it is also com- 
bined, as several nerve trunks of this plexus are functionless. The special 
composition is dependent, in addition to the direction and extent of the active 
power, upon the region of the primary bone injury. The higher this is 
situated the more nerve trunks are involved; otherwise a few may have 
branched off previously and therefore remain intact. This criterion applies 
particularly to the difference between an epiphyseal separation and a fracture 
of the diaphysis. Fracture of the clavicle is apparently an exception. Not- 
withstanding the fact that it is comparatively the most common, compli- 
cating paralysis of the arm is very rare. This, however, is readily compre- 
hensible when we consider that the effect of the force is here usually not 
vertical but is directed parallel to the body and is also exerted downward, 
especially in releasing the arm. 

In addition to this indirect, secondary damage to the nerves there are 
also direct, substantive injuries. Their first comprehensive description we 
owe to Duchenne; a minute knowledge of their localization to Erb. The 
nature of the damage and how it occurs intra partum is yet a matter of 
controversy. Erb-Duchenne paralysis 1 , as this variety is called, reveals 
itself in paralysis of the deltoid muscle, the biceps, brachialis internus, infra- 
spinatus, teres minor, and the supinators, and therefore includes the regions 
of the axillary, supra-scapularis, musculo -cutaneous, and radial nerves. Ifc 
is evident that the lesion must have affected the plexus in an area in which 
1 See volume on " Diseases of the Nervous System," p. 720. 



58 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

these nerve fibers lie close together, before they have branched, and thus, 
in the course of his investigations, Erb succeeded in finding a point at which, 
by means of the faradic current and the use of small electrodes, a common 
energetic contraction of these muscles could be produced. This region, known 
as Erb's point, is situated at the place of exit of the sixth cervical nerve, 
between the scaleni muscles. He referred the seat of the lesion to this point 
and the roots situated centrally from the plexus, therefore to the fifth and 
sixth cervical nerves, which has been confirmed by the subsequent investiga- 
tions of other authors. The clinical picture of this form of paralysis is de- 
scribed by Erb and by Duchenne as very characteristic: "The affected arm 
droops immotile to the side of the trunk; it is rotated inward and perma- 
nently extended; neither flexion of the forearm nor raising of the arm is 
possible; on the other hand movements of the fingers and of the hand are 
retained." According to both authors the very rapid degeneration reaction 
is conspicuous. In addition to this there is another clinical symptom — a 
contracture of the non-paralyzed muscles. The prognosis, according to Erb 
and Duchenne, is not invariably favorable; neglected cases sometimes do 
not recover. Although Duchenne advises early faradic treatment he believes 
that the same results can be obtained by the galvanic current. Erb's teaching 
is still correct; the only change that has arisen relates to the causal develop- 
ment of this form of paralysis. His investigations were made principally 
in adults. The functional disturbance, it is true, had existed from birth, 
but as to the course of the labor and the required operation he was neces- 
sarily dependent upon the anamnesis alone. As these always showed an 
operative termination (version and subsequent extraction, or traction at the 
shoulders to aid the trunk) he believed that, in head presentation especially, 
the traction of the shoulder with the index finger introduced in the form 
of a hook into the axillary cavity, and in version and extraction the difficult 
release of the arm and the energetic employment of the Prague method were 
at fault. The same factors, confirming Erb's opinion, are mentioned in 
the subsequent publications of other neuropathologists. Hoedemaker and F. 
Schultze add that in raising the shoulder and the arm, especially when the 
latter is directed upward or under the nape of the neck, the middle portion 
of the clavicle is approximated to the transvere processes of the seventh and 
eighth cervical vertebrae and thus compression of the fifth and six cervical 
nerves becomes possible. The greater the curvature of the clavicle and the 
less the amount of fat, the more likely is this pressure paralysis. The char- 
acter of all of the investigated material was the same: the cases were alwa}^s 
observed later, never during the course of the birth. That obstetricians were 
skeptical regarding this form of paralysis is little to be wondered. The simi- 
larity of the causal factors with those of injuries to the bones, the coincidence 
of the clinical symptoms, particularly the position of the arm, the unfavor- 
able prognosis, and finally the difficulty in diagnosis, especially in epiphyseal 
separation, warranted the suspicion that in the cases in question there was 
an injury to the bone which had not been recognized. As lately as 1880 



TRAUMA DURING BIRTH 59 

Kiistner mentioned this view in his monograph upon Injuries of the New- 
born. The labors of the last decade, however, have shown this opinion to be 
altogether erroneous. Aside from the fact that even obstetrically a number 
of positive cases of pure Erb-Duchenne paralysis have been reported, which 
in the last few years have also been positively confirmed by means of the 
X-rays, many investigators have studied the origin of this nerve lesion experi- 
mentally. An investigation from the present stand of this theory of develop- 
ment is all the more advisable since it furnishes exceedingly important criteria 
for an eventual prophylaxis. Erb-Duchenne paralysis has been observed after 
spontaneous head and breech presentations as well as after those of operative 
termination. In the former the children were always comparatively large 
with especial breadth of shoulders. While the birth of the head occurred 
unaided or only with slight assistance, the delivery of the shoulders was difficult, 
as they remained quite or almost within the transverse diameter of the pelvis 
or else the anterior portion was lodged behind the symphysis. The positive 
and only means of facilitating the labor is slight traction of the head. So 
long as this remains in the direction of the body axis the tension upon each 
plexus is the same, and unless there is too great force no damage results. 
The situation becomes critical only when the head is inclined toward one 
shoulder, to which the mechanism of the delivery of the shoulder is readily 
prone. If the tension is concentrated to one side of the neck alone a simulta- 
neous traction readily increases it to actual tugging or even tearing. Fieux, 
and subsequently Schoemaker and Stolper, have tested this method of de- 
velopment experimentally. According to them the fifth cervical nerve is 
not only first but most involved, the sixth later and to a less extent, while 
the seventh and eighth cervical nerves remain entirely unaffected. This 
division confirms the practical observation that the deltoid, the nerve of 
which proceeds principally from the fifth cervical nerve, may be paralyzed 
alone, and in the simultaneous development of other muscle areas its paralysis 
appears to be the most marked and most tenacious. This tugging upon the 
laterally inclined head in the deliveries that are otherwise spontaneous is the 
most common and probably also the most readily understood cause of develop- 
ment of Erb-Duchenne paralysis. According to the findings of Fieux and 
Schoemaker, when the anterior shoulder is compressed behind the symphysis 
the weight of the head alone may be sufficient, provided there is no support, 
therefore when it hangs over the perineum. This factor is of special signifi- 
cance in this form of paralysis occurring after an absolutely spontaneous 
delivery, the statement usually being made that the child was very large and 
the trunk followed slowly. In a case of this kind Polaillon believed a com- 
pression of the plexus by the clavicle, which had occurred previously intra 
partum, to be due to a too great compression of the shoulders in the bony 
pelvis. In head presentation, however, under these conditions, the clavicle is 
simultaneously forced toward the feet of the child and thus the possibility 
of compression of the plexus is very slight if not altogether improbable. The 
approximation of the clavicle to the vertebral column and the first rib and 



60 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

a possible compression of the plexus at this point only becomes active in head 
presentation when the finger is hooked in the axillary cavity, either incor- 
rectly from the side of the abdomen or when the back of the finger is intro- 
duced too far and its point during traction presses directly upon the clavicle. 
Finally, in spontaneous head presentation the eventual effect of exostoses of 
the pelvis much be remembered. Just as with the facial nerve at its point 
of exit from the stylomastoid foramen (Vogel) may Erb's point also be exposed 
thereby to pressure, which appears to be decidedly facilitated by deflection of 
the head, especially in a face presentation. 

Examples of this form of paralysis after the use of forceps are reported 
by Danyau, Depaul, Gueniot, Thorburn, Bollenhagen, and others. As proof 
of the effect of direct pressure of the apices upon the plexus the finding of 
the remains of pressure or distinct pressure marks in the region of Erh's 
point may be mentioned. That such a direct pressure effect is possible 
anyone may convince himself upon the manikin. The greatest danger lies 
in deflection of the head, therefore in anterior head, frontal, and face pres- 
entations, and becomes the more extreme the greater the grasp is lowered 
when locking the forceps and with the forceps applied in a vertical position. 
Naturally, in addition to this there is the danger of too great compression 
of the blades. According to Schoemaker and Stolper the rotation of the 
head by the forceps without a simultaneous tug has proved serious. Here 
the damage does not occur merely from simple compression toward the cer- 
vical vertebral column; on the contrary, the yielding of the muscles of the 
neck permits a simultaneous tension and torsion of the nerve trunks. This 
perhaps may explain the more serious prognosis of this form of paralysis 
than of paralysis of the facial nerve from forceps compression. On account 
of the comparatively broad attacking surface of the apex of the forceps the 
damage is not limited to the nerve alone and lesions of the surrounding 
area such as suggillations or large effusions of blood are not unusual and 
enhance and protract the injury to the nerve trunk. 

Cases of Erb-Duchenne paralysis after spontaneous labor and after head 
presentations with the aid of the forceps are very rare. The majority of 
those which have been reported have followed breech presentation. The 
most serious procedure is the release of the arms. From the experimental 
investigations of Schoemaker and Stolper it appears that upon raising the 
shoulder the clavicle primarily approximates the first rib; strong upward 
pressure with simultaneous compression toward the median line forces it 
against the vertebral column. Such a consequence arises when the arm is 
directed upward or under the nape of the neck, therefore with considerable 
shoulder breadth and narrow pelvis. The plexus is then liable to a com- 
pression either between the clavicle and first rib or between the clavicle and 
the vertebral column. In the cadaver this effect of raising the shoulder is 
decidedly increased by simultaneous pressure from behind; in practice it is 
more rare, as the release of the arms usually occurs from the back. Im- 
proper rotation of the trunk and release of the arm from the abdominal side 



TRAUMA DURING BIRTH 61 

of the child may perhaps bring about such a result. Notwithstanding the 
former opinion of Erb the plexus appears to be least endangered in the 
Mauriceau and the Prague methods. Here also, naturally, an inclination of 
the head, therefore deviation of the force from the axis of the body, is serious. 
Otherwise the fingers only meet ErVs point by strong curvature of the ter- 
minal phalanges and injure it the more they bore into the soft parts of the 
neck. In the main the Prague method has been rejected and is no longer 
in use. 

In accordance with this method of development we may contrast a form 
of paralysis due to compression of the plexus with that resulting from too 
strong traction. The prognosis of the former appears to be decidedly more 
favorable. In certain cases the outlook appears to depend exclusively upon 
the result of accurate faradic and galvanic tests of the existing irritability 
of the muscles and nerves — upon the reaction of degeneration. In regard 
to treatment, most authors believe the early institution of electric treatment 
to be essentially important. Nevertheless, months not infrequently elapse 
before an obvious result is attained. 

In the lower extremity the most serious accidents are superficial pressure 
ulcers or occasionally deep compressions or even wounds at the flexure of 
the thighs after difficult delivery in breech presentation, either with the 
finger or with the aid of instruments, hooks, or slings. All other lesions, 
particularly of the bones, are the result of a faulty method of version or 
extraction. The deviation of the fingers, hooks, or the sling from the 
flexure of the thighs against the upper thigh causes a fracture within the 
upper third. This misfortune has also occurred in version, due either to the 
crossing of the legs or to the attempt of the obstetrician to act from the be- 
ginning more upon the thigh than upon the foot. The diagnosis of this 
bone injury is easy: disturbance of function, crepitation, abnormal passive 
motility, and the findings of the X-rays. Epiphyseal separation of the 
femur and of the bones of the lower leg is due to incorrect turning of the 
extremity during traction. Therapeutically, in all of these cases, as in 
adults, accurate replacement is the first consideration. The later retention 
is most readily accomplished by the employment of permanent extension 
with vertical elevation. Less serviceable is the proposal of Crede to fix the 
extremity upon the trunks as by this means the dislocation is not sufficiently 
removed. 

The occurrence of luxations is the same as in the upper extremity. These 
are throughout merely congenital anomalies of development. 

In the lower extremity there is little opportunity for the development 
of paralysis from tension of the nerve trunks as the buttocks find no resist- 
ance upon their entrance into the pelvis. Nerve lesions are rare even in 
injury to the bone as here the abnormality of movement is of more influence 
than the greater employment of force. There remain, therefore, only 
paralyses of central origin, cerebral or myelogenous. The former are ob- 
served after difficult forceps delivery with contracted pelvis, are always 



62 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

unilateral, and usually involve the corresponding arm and the facial nerve. 
The disturbance of function within the lumbar cord is the consequence of 
difficult extraction in breech presentation, with stretching of the vertebral 
column so that the spinal cord itself tears or hemorrhage appears in its 
enveloping membranes. In either case paralysis of both legs occurs and if 
no other injury is present in the upper portion of the body — the cervical 
cord and brain — it is limited to this region alone. 



DISEASES OF THE UMBILICUS 

After the birth of the child the first indication is ligature and severing 
of the umbilical cord. If no contraindication, such as asphyxia, is present 
which requires some other method it is customary to wait until the reserve 
blood in the placenta and in the vessels of the umbilical cord has entered the 
body of the child. This method was first introduced at the beginning of 
the last century by Messmer and Ziermann and was later recommended by 
Budin and Schucking. Although the reasoning of these authors has been 
shown by subsequent investigations (Eross, Schiff) to be much exaggerated 
the method is nevertheless of some importance within certain limits. All 
authors caution against immoderation: compression of the uterus or stroking 
of the umbilical cord so as to force the last possible drop into the child. 
By such means the natural amount of blood in the infantile body is increased 
to an extent never before present and produces an artificial plethora which 
in its turn may give rise to undesirable conditions. Aside from slight hemor- 
rhage from the vagina (Porak), bloody vomiting (Violet), hemorrhagic dis- 
charge from the intestine, and prolonged, marked icterus, such excessive 
measures may produce cerebral hemorrhage, as was proven by Illing at 
autopsy. As a criterion for the proper time to tie and sever the cord mid- 
wives and even some physicians wait for the disappearance of the navel 
pulse. Ahlfeld has pointed out, quite correctly, that with strong respiration 
this may not infrequently be felt for a long time. A better indication that 
the reserve blood has been transferred sufficiently is the relaxation of the 
veins of the cord, which occurs much earlier and no less distinctly. 

Of the diseases of the umbilicus we are first particularly interested in 
navel hemorrhage. This condition, appearing soon after ligature and 
division of the cord, is principally due to the cessation of certain functions 
which physiologically are dependent upon the arrest of the circulation in the 
cord. In the active newly born infant the umbilical cord bleeds but little 
or not at all even without a ligature when respiration starts energetically 
and the child cries. Under these conditions life-threatening hemorrhages 
are exceedingly rare. In premature infants with deficient respiration, and in 
mature infants presenting asphyxia of the first degree the umbilical vessels 
remain engorged after birth and the arteries pulsate powerfully. Effective 
activity of the lungs is therefore of essential influence upon the amount and 



DISEASES OF THE UMBILICUS 63 

circulation of the blood within the umbilical cord and in this sense acts as 
a limitation. With the first dilatation of the chest the blood of the venous 
system is drawn out of the body toward the thoracic cavity and the contents 
of the pulmonary artery are drawn into the lungs upon their simultaneous 
expansion. The necessary result is a decrease of the blood pressure in this 
portion of the circulation and therefore in the veins of the cord. At the 
same moment this change also occurs within the area of the descending 
aorta and its terminal branches — the arteries of the cord — the supporting 
force and the action of the right ventricle now being absent. If such an 
absolute cessation of the circulation of blood in the umbilical vessels is pos- 
sible the active agent must be the coincident contraction of the walls of the 
vessels. According to Hoffmann, in extra-fetal life this begins placentaward 
and proceeds gradually toward the navel. The latter is soon reached after 
birth while the intraperitoneal portion of the navel vessels remains filled with 
blood for some time. In animals after hemorrhage had been arrested for 
some hours post partum Hoffmann was able to renew the bleeding and to 
maintain it for any length of time by the introduction of capillary glass 
tubes into the arteries of the naveL Deep respiration and energetic con- 
traction of the vessels may all the more readily attain their effect in the new- 
born as the height of the blood pressure, according to the investigations of 
Hoffmann and v. Basch, is of less significance than that of the adult. When 
these factors are inadequate there is necessarily a danger of subsequent 
hemorrhage from the navel vessels. The predisposition of asphyxiated and 
premature children is therefore obvious. The congestion of the navel ves- 
sels prevents a sufficiently powerful contraction of the vascular musculature. 
That, however, a deficiency of the latter alone may appear is proven by the 
occurrence of secondary hemorrhage in mature, vigorously breathing and 
crying children. In addition to the proper measures to increase respiration 
there must be a careful ligation of the umbilical cord. Secondary hemor- 
rhage, particularly when it endangers life, occurs less commonly immediately 
after ligation and division of the cord than later. This is readily explained 
in the case of asphyxiated or premature infants by the incompletely developed 
respiration, which soon becomes weaker. A gradual loosening of the ligature 
may then occur, particularly if it has been negligently applied. Wharton's 
jelly in time yields laterally to the ring-shaped pressure of the ligature. 
The inequality becomes the greater the richer the accumulation of mucous 
tissue. This readily explains the greater tendency to subsequent hemorrhage 
of umbilical cords rich in jelly. The navel bandage, however, which is ap- 
plied wet simultaneously, dries under the influence of the body temperature 
and of the bed and may become loose. Therefore, with a lack of caution in 
applying the ligature or with very stiff, inadaptable linen a displacement of 
the knot is at least conceivable. A special tendency to this is brought about 
by the unequal band compress separated merely by a simple knot. Finally, 
a narrow navel bandage readily cuts into the substance of the umbilical cord, 
a broad one only when there is much friability of the tissue. Such immedi- 



64 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

ate loosenings are especially dangerous as they easily escape immediate ob- 
servation. As a sure preventive it is usual to tie the cord provisionally 
and after a quarter or half an hour to re-tie it permanently, as well as to 
watch the condition closely. In another place I have stated that the double 
ligature which is advised in the Prussian Book for Midwives is of little ser- 
vice and tends to become loose. There is greater certainty if the cord is 
tied but once by a simple knot and loop. Instead of the linen bands y 2 to 
1 cm. in breadth which are especially recommended for midwives those of 
wool of the same breadth and with the same power of resistance are decidedly 
better on account of their greater elasticity. Finally, the time prescribed 
by the German law before the permanent tying is to occur is too short. It is 
better to advise attention to the child after the mother has been carefully 
looked after, i. e., after the delivery of the placenta is terminated. This will 
require at least one hour. If the nurse then gives the navel a superficial 
examination before she leaves the mother there will seldom be an uncontrol- 
lable secondary hemorrhage. Since the last half of the past century there 
have been quite a number of propositions for the positive control of the cord. 
Even surgical incision and tying of the vessels has been believed to be suit- 
able for introduction into general practice. It would lead too far to state 
all of the methods that have been proposed. Only one will be mentioned 
which was set forth about 1870 by the French school (Budin, Tarnier) and 
at first was received with much enthusiasm: tying by India rubber bands. 
These maintain a constant and energetic compression and are not subject to 
subsequent loosening. Later investigations in the Clinics at Leipsic and 
Dresden met with good results. Nevertheless this method has not been gen- 
erally introduced into practice, possibly because its application by one per- 
son without assistance offers too great difficulty and demands great experi- 
ence and skill. Naturally, to combat an existing hemorrhage only a new 
tying of the navel cord centripetally from the first can be considered. When 
the blood loss is considerable, to prevent collapse a plentiful supply of heat, 
the administration of wine, brandy with water, and hypodermics of ether and 
camphor should be considered. [Camphor in ether is very painful. — ■ 
Editor.] 

A second critical period for vascular hemorrhage occurs during the 
process of healing of the navel, at the time when the vessels are detached — 
when the cord separates. It is then a question whether the closure has 
occurred so far centripetally at the height of the umbilical ring that it is 
able to offer sufficient resistance to the flow of blood. As already mentioned 
the peritoneal portion of the navel vessels remains open for some time after 
birth and is filled with blood. The tubes of the vessels are as a rule obliter- 
ated by agglutination and adhesion of the intima. A thrombosis, which 
however appears to be rather exceptional, may lead to a favorable conclusion if 
other phenomena are absent. Deviations occur primarily through the dif- 
ferent forms of infection. In gangrene and putrefaction the stump of the 
umbilical cord swells, the vessels dilate and again become permeable. Septic 



DISEASES OF THE UMBILICUS 65 

infection of the navel wound leads to inflammation of the vessels whereby 
they are changed into a tube with rigid walls and existing thromboses are 
destroyed. In the same category probably belong such sequels as BuhPs 
disease and WinckePs disease. 

Syphilis is particularly serious since either the general condition of the 
child in itself predisposes to septic and pyemic affections and as a matter 
of fact is very often associated with them, or changes are brought about 
which have an unfavorable effect or prevent closure of the vessels. In the 
latter connection luetic vascular disease plays a much smaller role than the 
focal affections of the lungs (pneumonia alba) and of the liver (interstitial 
hepatitis, gummatous nodules). The only prophylaxis consists in the pre- 
vention of septic infection, therefore strictly aseptic or antiseptic measures. 
The syphilitic new-born must also be speedily subjected to specific treatment. 
An immediate result, before the sloughing of the navel, can scarcely be ex- 
pected. In the treatment of slight hemorrhage cauterization with silver 
nitrate and a compression bandage (preferably of adhesive strips) come 
under consideration. In severe hemorrhage surgical ligature is recom- 
mended, especially if the necessary material is at hand. Dubois's method 
of tying the navel has been found no less successful. Two hare-lip needles 
are passed through the navel at right angles to each other and the second 
underneath the first. A silk thread is then twisted around each needle, 
partly in the form of the figure 8 and partly in a circle, and fastened at the 
base of the navel. When a severe blood loss has occurred the weakness and 
collapse must of course be treated in the manner previously indicated. 

The vascular hemorrhages thus far mentioned are in the majority of 
cases limited; life-threatening bleeding is among the greatest rarities. A 
local hemorrhage can always be controlled by the treatment indicated. Ac- 
cordingly various authors differentiate, under the term omphalorrhagia, a 
certain form of hemorrhage characterized on the one hand as parenchyma- 
tous from its diffuse distribution over the entire umbilical wound, and on 
the other as profuse, abundant, uncontrollable. We owe to Grandidier the 
first comprehensive description of this pathologic condition. According to 
this author the hemorrhage begins shortly after the cord separates, rarely 
earlier. The hemorrhage appears as if coming from a sponge. The lumina 
of the vessels, as the sources of the hemorrhage, cannot be seen even by 
sponging. Sometimes the hemorrhage threatens life from the onset; in 
other instances it is at first slight and increases by degrees, rapidy or slowly, 
continuously or intermittently. Local compression has but a transitory 
result at most. Grandidier calculates the mortality as over 80 per cent. 
According to the character of the hemorrhage death occurs soon after the 
onset, mostly after a few days or at the beginning of the second week of life; 
more rarely after a longer duration, in the third or fourth week. The prin- 
cipal accompanying symptoms are anemia, collapse, or gradual loss of 
strength. Grandidier regards such hemorrhages as idiopathic. This 
naturally can be stated only of those cases in which every other symptom of 
6 



60 DISEASES OF THE NEW-BOItN IN THE FIRST DAYS OF LIFE 

disease is absent and the inability to control the hemorrhage is the only 
reason for assuming a hemorrhagic diathesis, 1 that is, a deficient coagula- 
bility of the blood. But these diffuse, uncontrollable hemorrhages are very 
rare, especially in hemophilic families. On the contrary, the majority of 
cases show other signs and symptoms indicative of a constitutional disease 
and accordingly hemorrhage from the navel must be regarded as secondary 
and symptomatic. Of special import in this connection are marked jaun- 
dice associated with some degree of cyanosis and early somnolence. Some- 
times the symptoms on the part of the digestive tract are primary: simple 
dyspepsia, vomiting diarrhea. In the further course of the affection there 
are hemorrhages from other regions; stomach, intestines, cutaneous ecchy- 
moses or large suggillations. Acute septicemia should first be considered. 
Most of the cases have occurred in the pre-antiseptic period and in foundling 
hospitals. With the improvement of the hygienic local conditions it has 
been possible to diminish the previously alarming frequency and in conse- 
quence of improved antiseptic treatment of the navel such affections have 
become exceedingly rare. The results of pathologico-anatomical and bacte- 
riologic researches in the last decades have confirmed the view that these 
affections are of septic origin. The most serious effect of congenital syphilis 
is that it favors a possible septic infection. Whether, in addition, a sub- 
stantive etiologic importance must be attached to this uncontrollable, diffuse 
hemorrhage has not yet been decided. This view, first propounded by 
Behrend, and later by Mracek and others, has been decidedly weakened in 
the last decade by the demonstration of streptococci. The chief element in 
the treatment of the affection consists in a careful observation of prophy- 
laxis, therefore cleanly, aseptic care of the navel. The therapeutic measures 
to arrest hemorrhage are the same as have already been prescribed in the 
treatment of hemorrhage after the cord has separated : first compression, then 
acupuncture or encircling of the navel by means of two hare-lip needles. A 
solution of iron chlorid, formerly so often employed, on account of its strong 
corrosive action will probably be of use only in exceptional cases when no 
other aid is at hand. More advisable in recurrent hemorrhage from the 
stitched canal is the application of plaster of Paris. In addition to this 
local treatment injections of gelatin have recently been employed. 

The process of healing of the navel corresponds clinically as well as patho- 
logico-anatomically with the course of the healing process of anemic necrosis 
of the skin. The tissue of the umbilical cord is dependent for its nutrition 
entirely upon the circulating blood in the three vessels of the cord. A sub- 
stantive supply is first produced fetalward from the boundary of the skin 
and amnion by an independent vascular net. From the superior and inferior 
epigastric arteries, from the amnionic sac with the urachus, and from the 
furrow of the liver along the vein of the umbilicus small vessels pass to the 
umbilical ring and by ramification and anastomoses they form in its im- 
mediate surroundings the subperitoneal arterio-umbilical circle from which 

1 See Vol. II, " Diseases of Metabolism and of the Blood," p. 388, et seq. 



DISEASES OF THE UMBILICUS 67 

branches pass through the umbilical ring and the linia alba to the surface 
and disappear within the subcutaneous and cutaneous tissues of the navel 
skin, forming capillaries. Superficially this vascular apparatus terminates 
precisely at the point of insertion of the amnion. Centrally, as a rule, the 
boundary zone has the form of a funnel-shaped depression, as the skin for 
a distance averaging 1/2 to 1 cm. continues upon the umbilical cord, that 
is, its tissues enter into the skin of the navel. This substantive vascular 
system is entirely uninfluenced by the exclusion of the placental circulation. 
With this change the only source of nutrition ceases at once, the tissue of 
the umbilical cord dies, and with sufficient air undergoes a gradual drying 
or mummification. The separation of the dead from the living tissue occurs 
through a demarcating inflammation. Epstein and Eross have recently 
denied this fact. It is true that with an entirely aseptic course there is 
usually no marked reddening of the immediate surroundings. Nevertheless, 
aside from the fact that in the desquamation of necrotic foci this is usually 
poorly defined in the new-born in the first days of life it may even be con- 
cealed by the overfilling of the cutaneous vessels. Furthermore, the exten- 
sive emigration of white blood corpuscles has been frequently proven. Under 
their influence the amnion is first loosened from the skin of the navel, then 
the artery, and lastly the vein. In the normal and vigorous child this proc- 
ess is usually completed by the fifth or sixth day; in debilitated and prema- 
ture infants somewhat later. In contrast to the original thickness. of the 
umbilical cord only a small granulating wound remains which, through the 
shortening of the intraperitoneal umbilical vessel strands, simultaneously 
retracts at or below the level of the abdominal cover. After the umbilical 
cord has fallen off the invagination continues somewhat more rapidly. The 
progressive decrease in the wound is usually terminated by the twelfth or 
fifteenth day. The cicatrix is finally sunk in the umbilical groove, which 
is closed superficially by an upper and lower fold of skin. 

As regards the nature and rapidity of the healing process of the umbilicus 
the funnel-shaped depression of the necrosed tissue in the integumentary 
portion of the umbilical cord is of great importance. The formation and 
position of the zone of demarcation resulting therefrom in relation to the 
superficial boundary of the amnionic skin form an essential means of stimu- 
lation of all of the active factors in the sense of a diminution of the wound, 
therefore in the shriveling desiccation of the cord and particularly in the 
retraction of the intraperitoneal navel vessel strands. Even with an out- 
wardly normal length of navel skin this depression varies. On account of 
the smallness of the space deviations of 1/2 cm. play a great role. This 
explains why in the one case the entire healing of the wound appears to 
occur by depression and but little of the boundary remains for the later 
covering with skin, while in another case which may be externally quite simi- 
lar the inverse occurs. The well-nourished fetal tissue may exceptionally 
reach to the superficial boundary of the amnion and even beyond. The latter 
condition is known as resistant vascular stump. Under these circumstances 



68 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

the wound which remains after the cord separates is the larger; the further 
closure occurs almost exclusively by secondary skin formation from the 
marginal area and accordingly is decidedly slower. 

The results are similar when the superficial amnionic boundary is unusually 
near to the surface of the abdomen or is situated upon it (amnionic navel). 
On the other hand, the inverse condition — a particularly long cutaneous 
process with an insufficient depression of the necrosed tissue of the navel cord 
— is without importance and only results in an abnormality of the healed 
cicatrix and umbilical groove. 

As in every wound healing under similar conditions — therefore by sec- 
ondary intention — prolongations of this kind show here also a great tendency 
to immoderate granulation proliferation. External irritation either of me- 
chanical or infectious nature is present in the new-born in excess. In this 
manner the so-called umbilical fungi — bright red, broad-based, more or less 
pediculated granulomata — originate which maintain a profuse seropurulent 
secretion. As a rule they attain the size of a pea or small strawberry and, 
in consequence of the intraperitoneal shortening of the umbilical vessel 
strands, are usually so concealed in the umbilical groove that only the tip is 
visible between the cutaneous folds. In very neglected cases a length of 
several centimeters has been reported. Spontaneous healing becomes exceed- 
ingly difficult although by no means impossible. Kiistner, Hiittenbrenner, 
Villar, and Pernice report instances of a delicate although faulty epithelial 
cover. Also, in adults, mollusca pendula originating in the depth of the 
umbilical groove find their simplest explanation in this manner (Heinecke, 
Kiistner). Prophylactically these conditions are best met by the careful ob- 
servation of cleanliness and early stimulation of the healing of the wound: 
touching lightly with a dilute silver nitrate solution, the use of astringent 
powders or salves (dermatol, iodoform, sanoform, etc.). Repeated cauteriza- 
tion of small proliferations with the silver nitrate pencil and separation of 
larger ones by the scissors after previous tying with a sterile silk thread bring 
about the most rapid results. 

In addition to these tumor-like structures in the umbilical wound which 
are characterized microscopically as pure granulomata, other growths appear 
in the first weeks of life which macroscopically have the same form but the 
structure of which comprises epithelial tissue either in the form of cylindrical 
surface epithelium or tubular glands and smooth muscle fibers in large 
amounts. These in combination with adenoid interstitial tissue usually have 
a peripheral cover resembling the intestinal mucous membrane and corres- 
ponding with the interwoven bundles of the central zone. The first accurate 
investigations we owe to Kolaszek and Kiistner. The latter author considered 
them substantive proliferations originating from the allantois passage or its 
residues which have remained permeable up to the navel ring, and called them 
adenomata. Kolaszek suspected the matrix in the tissue of the ductus om- 
phalo-mesentericus and regarded the simple protuberance of the walls more 
likely as a persistent vitelline duct. This view was confirmed by the later 



DISEASES OF THE UMBILICUS 69 

investigations of Schulze, Ohlfeld, Siegenbeck van Heukelom, Tillmanns, 
Pernice, etc. According to the extension of the malformation two varieties 
may be differentiated. Most commonly there is a retention and further de- 
velopment of a peripheral portion in the course of the navel ring and the 
zone of demarcation. Centrally the vitelline duct is entirely destroyed and 
the intestine completely closed. After the cord falls off there exists within 
the navel wound a canal with a blind termination proceeding outward toward 
the peritoneum. With the increase of intra-abdominal pressure due to be- 
ginning intestinal digestion, or perhaps more rapidly in consequence of crying, 
vomiting, pressure, etc., this depression is gradually forced outward and in 
time a protuberance occurs. The previously internal mucous membrane 
covering then becomes the external lining membrane and the muscular wall, 
formerly the peripheral part, becomes the central trunk. Contraction near 
the point of insertion, inflammatory hyperplasia of the upper segment in con- 
sequence of venous stasis, mechanical or infectious irritation, soon give to 
this protuberance a polyp-like appearance. The second form, which is much 
more rare, is due to the persistence of the omphalo-mesenteric duct with 
opening into the intestinal canal. The protuberance here appears more or 
less like the finger of a glove, cylindrical. At the height of the growth there 
is a small opening from which mucus and the contents of the intestine some- 
times exude. Transverse section reveals first, from without inward, the 
intestinal mucous membrane, then smooth muscle, and lastly the mucous 
membrane. This development is in conformity with the microscopic struc- 
ture and the designation proposed by Siegenbeck van Heukelom and Pernice 
as intestinal ectopia or prolapse of the diverticulum is well justified. Accu- 
rate knowledge is naturally furnished only by microscopic examination, but 
the macroscopic appearance reveals certain peculiarities in contrast to granu- 
lomata. This is particularly true in regard to the character of the secretion, 
which is not seropurulent but mucoid and thready. Also the development 
occurs gradually, as is apparent from the previous description, and is limited 
to a certain maximum. Finally, these intestinal ectopias never occur in the 
first days of life but as a rule about the third week. 

Tillmanns and Weigert have expressed the opinion that similar formations 
may originate from the stomach and especially from the region of the pylorus. 
They ba,se this view upon the careful observation of a case in which the 
secretion was of a distinctly acid reaction and the structure of the mucous 
membrane corresponded to that of the pylorus. Quite a number of hypotheses 
have been advanced as to the method of development. Siegenbeck van Heuke- 
lom has opposed this view and demonstrated that the structure of the mucous 
membrane which has been described is generally distributed in the intestinal 
canal in early life and not until the beginning of bile secretion do Lieber- 
kuhn's crypts and beaker cells appear. Accordingly the finding of Tillmanns 
and Weigert is constant in the intestinal ectopias which originate from a 
partial persistence of a peripheral portion of the vitelline duct and the other 
change is only noticeable with a complete retention. 



70 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

Naturally, prophylactic measures cannot be employed against these struc- 
tures. Therapeutically the best measure is excision after tying, the latter 
process being necessary on account of the medium-sized blood-vessels situated 
within the nuclear zone. 

The most frequent and important disturbance of the process of healing 
of the umbilicus is accidental wound infection. A special predisposition for 
its development is assured by the principal factor of anemic superficial 
necrosis. With a certain amount of moisture — and in the new-born the fre- 
quent wetting of the diapers and of the navel bandage is sufficient — the 
necrosed tissue supplies a particularly fertile nutritive medium for the bacteria 
of decomposition. No less favorable are the conditions for the colonization of 
pathogenic microorganisms, streptococci, staphylococci, those of erysipelas, 
tetanus, etc., for within the range of the point of separation, on the border 
of the well-nourished and active tissue there is a zone of deficient nutrition 
and lessened resistance. On account of the active contact with the surround- 
ings (strong vascular filling, cell proliferation, cell emigration) the bacterial 
products of metabolism are very energetically absorbed and new paths are 
opened to the aggressive activity of pathogenic germs by the establish- 
ment of numerous lymph spaces brought about by the separation of dead 
tissue. 

The transmission of deleterious products occurs wholly by contact. Not 
only soiled hands, dirty scissors, bandage material, and the like, but contami- 
nated bath-water, bath-tubs, and sponges are responsible. According to present 
views infection by means of the air is always secondary. In pre-antiseptic 
times septic disease of the mother played an etiologically great role. The 
most numerous and severe cases of navel infection were observed during epi- 
demics of puerperal fever. Therefore it was not surprising that with slight 
knowledge of the cause of the disease an intrauterine transmission on the part 
of the mother was first considered and puerperal fever of the new-born was 
spoken of ! Only with the founding and the further development of the theory 
of wound infection was the untenableness of this view apparent, and the more 
so the greater the results of careful prophylaxis. Children of healthy mothers 
were even more often and more severely affected, whereas, with puerperal 
fever in the mother, the process of healing of the navel in the infant was 
entirely without reaction. But the influence of a septic infection of the 
maternal genital organs cannot be altogether excluded. This influence, how- 
ever, arises chiefly from the fact that the lochia abound in pathogenic organ- 
isms, the transmission of which to the navel of the new-born is greatly facili- 
tated when the same nurse is employed for both mother and child. Further- 
more the lochia of the normal lying-in woman from the third day are a veritable 
breeder of bacteria of decomposition. Finally, there is the possibility that 
the child may have introduced septic material into its own body from the 
septically diseased organs of the mother. Theoretically this can certainly 
not be denied. Notwithstanding the fact that on account of the repeated 
cleansing of the infantile body a further retention appears to be scarcely 



DISEASES OF THE UMBILICUS 71 

conceivable, if this should exceptionally be the case, in contrast with the 
frequent opportunity of contact in the first days of life this mode of trans- 
mission plays a very subordinate part. 

A positive differentiation of the infectious diseases of the navel according 
to the nature of their origin is clinically impracticable. Apart from the 
unanimity of the pathologico-anatomical course there is almost always a 
mixed infection. Therefore the former division, according to the degree and 
extent of the local changes (blennorrhea, omphalitis, ulcer, etc.), is of little 
use as the possibility of a general infection is not sufficiently considered. In 
practice the division into locally limited infection transmitted to the rest of 
the body and general septic or pyemic disease of the navel appears to be the 
best and simplest. Primarily the putrefactive destruction of the necrosed 
remains of the umbilical cord — the gangrene — remains localized. With the 
dissolution of the decomposed masses the danger to the organism of the 
intake of toxic substances is removed. The development of strong granula- 
tion forms a positive barrier to a later infection, which only occurs through 
injury. It is true the bacteria of decomposition furnish a favorable soil 
for the colonization of virulent pathogenic microorganisms, but even these 
septic germs and their diseases may be limited to the navel and its immediate 
vicinity. Why and when this happens is little understood. We usually 
assume that either the germs themselves possess an attenuated virulence or 
that the child is less susceptible and its tissues offer greater resistance. The 
latter is especially true of robust infants in contrast to the feeble, premature, 
or luetic. The external signs of contamination are most frequently decided 
redness and swelling of the immediate vicinity either greatly beyond the 
norm or continuing after the separation of the cord. In the former case 
the local changes may occasionally assume such a degree and extent that 
we are justified in speaking of a phlegmon of the navel and of the wall of 
the abdomen. Simultaneously there is usually a more or less increased 
secretion of pus with marked proliferative granulation, especially after disso- 
lution of the cord. The position of the wound, in the depth of the navel 
groove, by adhesion of the superficial cutaneous folds readily gives oppor- 
tunity for the retention of secretion. A wider distribution of the destruction 
to the skin of the navel, whether in the form of a purulent process (ulcer) 
or of gangrene, is much more rare. So greatly feared in the pre-antiseptic 
period, this condition now occurs only occasionally in debilitated and syphilitic 
children. All of these varieties may terminate in complete recovery with 
proper antiseptic treatment. On the other hand, with a prolongation and 
greater distribution of these local processes it is readily comprehensible that 
the danger of a general infection is increased. Nevertheless, the development 
of a peritonitis by continuity, regardless of the small layer of separation, is 
very infrequent. The septic virus in the navel of the new-born has a much 
easier means of direct communication with the interior of the body in 
the numerous lymph tracts which follow the navel vessels. These may also 
aid a rapid propagation to the interior without conspicuous superficial changes 



72 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

in the navel wound and its surroundings, while the process of healing, on 
the contrary, apparently occurs without reaction. 

Wharton's umbilical cord tissue continues immediately and uninterruptedly 
through the umbilical ring intraperitoneally in a broad and distinctly de- 
veloped adventitia of the navel arteries. Successful injections have likewise 
revealed a direct connection of a rich, narrow-meshed net of lymph vessels. 
The conditions on the part of the vein are less favorable, a special adventitia 
being absent. The perivascular connective tissue terminates at the height 
of the umbilical ring. Here the fibers of the rectus fascia reach the true 
vascular wall (the media), without, however, joining or intimately associating, 
so that the vascular tube alone passes through the linia alba. 

The lymph vessels in the perivascular layer, although in themselves some- 
what broader, in comparison to the arteries along the vein are decidedly less 
numerous. Therefore anatomically the propagation of a septic virus corres- 
ponding to the course of the artery is decidedly facilitated — a fact which 
finds confirmation in pathologico-anatomical investigation, which shows that 
periarteritis and arteritis are most common occurrences in themselves as well 
as the causes of a general infection. Periarteritis may remain a simple cellu- 
lar tissue inflammation, but may also lead to suppuration and to the formation 
of phlegmons or abscesses. The latter are situated below the navel, between 
the peritoneum and the abdominal fascia, extend usually only to the vertex 
of the bladder and open into the navel wound. A further distribution to the 
base of the bladder or to the scrotum and the inguinal region is very rare. 
The transmission to the vascular wall may occur outside of the navel ring, 
sometimes within or beyond, or occasionally at a distance of 1 to 2 cm., and 
with a decided extension in the perivascular connective tissue may not occur 
at all. Arteritis, like periarteritis, does not tend to distribute itself centri- 
petally, without limitation; on the contrary, it generally terminates at the 
curve of the vascular strands in the region of the bladder. The further con- 
tinuation to the retroperitoneal connective tissue upon the anterior side of 
the vertebral column, thence to the abdominal organs, and finally to the 
thoracic cavity is certainly exceptional. It is a remarkable fact that the 
development of peritonitis in connection with isolated disease of the arterial 
strands is comparatively subordinate. In the autopsy reports the lesions of 
lobar and lobular pneumonia with consecutive pleurisy decidedly preponderate. 
The causal connection readily becomes clear if the vasa vasorum are invoked 
in explanation. Not rarely these pulmonary affections were the only compli- 
cation. All other organic lesions were more or less combined. As in the 
other general infectious diseases the organs principally affected were the 
liver, spleen and kidney. All of the stages from a beginning cloudy swelling 
to complete softening were observed. With extensive disease of the liver 
jaundice is correspondingly conspicuous. In the later stages of insidious 
chronic cases apostematoid foci, due to embolic propagation, may appear at 
various points. Arthritic suppuration and periostitis have been mentioned. 
Finally it must be stated that complicating diseases of the brain in the form 



DISEASES OF THE UMBILICUS 73 

of diffuse encephalitis and meningitis and exceptionally isolated focal disease 
have been found. 

Septic inflammation of the vein of the umbilical cord, as already mentioned, 
is much more rare. It may occur simultaneously with that of the arteries 
or alone. Here also the transmission to the vascular wall occurs in the 
vicinity of the navel wound or at a greater or less distance from it. Corres- 
ponding to the direction of the blood current the phlebitis endeavors to extend 
itself more to the central portion. From the point of transmission to the 
vascular wall the disease usually extends to the liver, and cases in which the 
vein has been found greatly altered in its entire length are by no means rare. 
Accordingly, in the further course the distribution by means of the circula- 
tion should seemingly be prominent. It is peculiar, however, that here the 
development of peritonitis is decidedly more common. More comprehensible 
is the early and marked change in the liver. According to Widerhofer this 
appears as a septic inflammation of Glisson's capsule or as a phlebitis of 
the portal vein. Hepatogenic jaundice, which is the chief indication of this 
condition, has depreciated as a differentio-diagnostic sign on account of its 
similar occurrence in primary arteritis and periarteritis. The other lesions 
coincide with those found in diseases of the artery and have already been 
mentioned. 

Although the first propagation of the septic virus occurs entirely by way 
of the lymphatic tracts the further distribution rarely maintains the character 
of pure sepsis; on the contrary, by the implication of the blood channels it 
more often presents that of a mixed infection, of a septicopyemia. 

The great predisposition to general infection which is furnished by in- 
fectious diseases of the umbilicus in the new-born is particularly evident in 
a review of the publications of the pre-antiseptic period. In the foundling 
asylums and maternities the mortality from septicemia and pyemia was 
enormous; during the time of puerperal epidemics almost devastating. Be- 
sides the rapidly progressive cases of so-called blood decomposition there 
were also phlegmonous, erysipelatous, and gangrenous inflammations of the 
surface of the body; multiple inflammations of the serous membranes, bones, 
and joints were very common, and even gangrene of the fingers, nose, lobes 
of the ears, and of entire extremities were not infrequent occurrences. Epstein, 
as lately as the middle of the seventh decade of the last century, reported 
the total mortality of the Foundling Asylum in Prague as 30 per cent., of 
which the majority gave a pathologico-anatomical diagnosis of septicopyemia. 
The betterment of these exceedingly deplorable conditions began with the 
minute investigation of the cause and nature of wound infection and increased 
as the observation of proper prophylactic measures gained prominence. 
Sporadic results were noted toward the end of the same decade. The real 
turning-point occurred about 1880, at the time of the general introduction 
of asepsis and antisepsis into obstetrics. With the decrease of puerperal 
fever the amount of the transmitted virulent material was lessened. The 
principal effect, however, was occasioned by a change in the general views, 



74 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

which assigned the greatest importance to the danger of contact infection 
and accordingly regarded absolute cleanliness of instruments, bandages, the 
hands, etc., which came in contact with the wound as a primary necessity. 
Epstein reported in 1888 that, thanks to the observation of precautionary 
measures, the total mortality in the same Foundling Asylum in Prague had 
decreased to nearly 5 per cent., of which only about one-third were due to 
pyo-septicemia. Futher advances have since been made and to-day severe 
cases of pyemia and septicemia in association with a local infection of the 
navel are exceedingly rare even in foundling asylums and maternities and 
are only observed in completely neglected and destitute children. While in 
a comparatively short time the danger of the more serious complications was 
decidedly decreased, much was still lacking for their complete disappearance. 
Eross, in his publication from the first obstetrical clinic of Budapest in 1890, 
stated that among 1,000 infants only 320 experienced an uninterrupted heal- 
ing of the navel; the remaining 680 cases showed mild or severe deviations 
and sometimes fatal disease; or, reckoning by the temperature curve, 43 per 
cent, showed an increase which, in 51 per cent., therefore in more than one- 
half, could be referred to infection of the navel. This still great mor- 
bidity was confirmed by a similar compilation from the second obstetrical 
clinic in Budapest (Tauffer). Besults from other clinics (Innsbruck, Halle, 
etc.) are much more favorable although still remote from what can be re- 
garded as ideal or even satisfactory. As the result of these investigations 
the question of infectious navel disease, its treatment and especially its pre- 
vention has recently been renewed. Many changes of the methods formerly 
in vogue have been proposed and tested in practice. Although a certain differ- 
ence of opinion still exists as to individual methods all authors agree to the 
principle that continued improvement can only be attained by means of the 
strictest prophylaxis. 

The recognition of infection from the local changes is easy after what has 
been stated. The physician need only examine the navel carefully from time 
to time. When transmission of phlegmonous inflammation to the arterial 
vessels occurs these, corresponding to their divergent course below the navel, 
may occasionally be felt as hard, sensitive strands. Hennig's observation — 
retraction and marked pallor of the triangular area of the abdominal skin 
situated medially, perhaps with a streaked redness of the lateral borders over 
the arterial strands — at the time regarded as characteristic, has not been 
confirmed by other authors. Periarterial suppuration produces swelling and 
redness of the overlying abdominal skin. In perforation into the umbilical 
wound a suppurative fistula develops, the contents of which may be discharged 
by pressure from the symphysis or spontaneously by an increased action of the 
abdominal muscles (crying, vomiting). 

Of particular interest is the subject of an already developed general infec- 
tion. We must always be prepared for this if the process of healing of the 
navel is not normal. As already mentioned, however, it may occur without 
any external evidence and when the wound apparently heals without reaction. 



DISEASES OF THE UMBILICUS 75 

First, septicemia ! Most important is the relation of the body temperature. 
As all other substantive causes of fever on the part of the intestine, the 
lungs, etc., in the first days of life, are essentially subordinate, every 
rise of temperature is suspicious, especially if it is continuous and has 
the character of continued fever with slight morning remissions. In 
how far the effect of absorption or intoxication can be considered de- 
pends upon the influence of local antiseptic measures. Simultaneously the 
pulse is decidedly increased. A possible disproportion to the height of the 
temperature in the new-born, however, does not have the same differentio- 
diagnostic importance as in the adult. Very conspicuous is the early impair- 
ment of the general condition: at first restlessness, whimpering rather than 
crying, suffering expression, and finally somnolence, sopor, coma. With 
marked cerebral irritation or disease of the brain there is a typical muscular 
restlessness in the form of tremor of the arms or tonic and clonic contractions. 
In peritonitis the infant lies with the legs and body quiet but twitches upon 
any contact. The ingestion of food is more or less limited, either in quantity 
or by subsequent vomiting of that which has been swallowed. In addition, 
in the further course there is frequent and at times very profuse watery 
diarrhea (septic gastro-enteritis). Finally, especially in the severe forms, 
hemorrhages into the skin from the mucous membranes of the nose and mouth, 
hemorrhagic vomiting and bloody discharges may occur. 

In this manifold, readily recognizable form septicemia of the new-born 
occurs only exceptionally. As a rule the individual sequences are much more 
limited in number as well as extent. Occasionally there is only the simple 
picture of a dyspepsia or enteritis: The temperature is not elevated; with a 
constant decrease in weight the child gradually becomes feebler or may perish 
in a few days in profound collapse. In cases of this kind the digestive dis- 
turbance present may readily be regarded as the principal factor; or the 
cause of death, particularly where debilitated or premature children are con- 
cerned, is registered under the common designations atrophy, marasmus, de- 
bilitas infantum. A similar error may occur with a febrile course when the 
symptoms of individual organs are particularly prominent. Here, besides 
the digestive tract, the respiratory organs must be considered, more rarely 
the brain and the cerebral membranes. Such errors can only be averted when 
the danger of a general septic infection during the time of the process of 
healing of the navel is considered and when it is remembered that a substantive 
disease of any of these organs during the first days of life is essentially rare. 

The duration of the disease depends upon the severity of the primary 
infection; that is, the rapidity of the distribution. There are cases which 
terminate fatally within a few days and others in which the entire pathologic 
process is subject to gradual development, death being postponed until the 
second or third week. 

Pyemia differs from septicemia by the appearance of metastatic suppura- 
tion due to thrombus displacement. Naturally, here, as in other conditions, 
the lung is primarily endangered. If the pneumonic focus is close to the 



76 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

pleura the development of a purulent pleurisy, an empyema, is the immediate 
consequence. Smaller particles which readily pass the pulmonary circulation 
may occlude the capillaries of the muscles of the extremities. Next in order 
are the skin, epiphyses of the bones, joints, the internal organs, and finally 
the brain. Aside from the extension of the suppuration the prognosis depends 
principally upon the organ affected. If the vital organs are uninvolved and 
the strength of the child continues the process may terminate in recovery. 
Important in a clinical respect is the fact that the development of pyemia 
may occur quite late, even several weeks after birth, and may be observed a 
long time after the umbilicus has healed. 

Therapeutically the principal factor is the careful observation of the neces- 
sary prophylaxis. Absolute cleanliness of the hands and of all articles, instru- 
ments, ligature material and bandages which come into contact with the 
navel is the chief requirement, not only when tying and severing the cord 
after birth but also in the later treatment, whenever the bandage is- changed. 
These measures in the majority of instances are [too often left, Editor] under 
the control of the nurse. In those cases which are under the direction of 
the physician it is impossible for him to supervise the subsequent dressing 
of the navel, especially if the exclusion of moisture is to be regarded as an 
important factor in hindering putrefaction, as the bandage must be immedi- 
ately changed when it has become wet. Nevertheless, every physician can 
do much to maintain the necessary precautionary measures. His attitude is 
an example for the nurse of what is to be done and left undone. Although 
the nurse may depart from the fundamental principles which have been given 
to her in her very brief course of instruction, the broadening of her later man- 
ner of thought is more greatly influenced by the actions of the physician 
than by the laws which control the situation. Professional interest increases 
the care, professional indifference leads to negligence. If the physician sees 
to it that the scissors and bandage material are thoroughly sterilized before 
use and placed in an antiseptic solution the nurse is less likely to neglect this 
precaution when away from his observation. More important even is his 
supervision of the nurse. The bandages are not only to be clean but are 
to be kept in a proper manner. The child shquld always be looked after before 
the mother. If, for certain reasons (urination, catheterization, movement of 
the bowels), this is impossible, the nurse must afterward thoroughly cleanse 
the hands. This precaution should also be observed when the nurse has 
handled the bed-clothes of the mother. A change of the navel bandage must 
never be made without a previous cleansing of the hands. Touching and 
manipulation of the navel cord or of the wound with the fingers is to be 
strictly avoided. If the physician gives this advice to a person who has not 
nursed for him previously, in the presence of the mother or one of the relatives 
she is more likely to feel herself under constant surveillance and will endeavor 
to prevent negligence. Every physician, however, even during the lying-in 
period, should carefully observe the condition of the navel. If now and then 
he informs himself of the condition of the navel wound, best before the child 



DISEASES OF THE UMBILICUS 77 

is bathed, this serves as an important incentive for strict nursing and gives 
him an opportunity to test the care and skill of the nurse in applying the 
bandage. 

The rules for the care of the navel have been essentially changed and 
improved in the last few years through the stimulation consequent upon the 
publication of Eross from the Budapest Clinic. Previously it was generally 
held that the remaining stump of the cord should have a length of about four 
fingers, but for the more certain prevention of gangrene and to aid mummifi- 
cation a greater shortening has proved to be exceedingly advantageous. Two 
methods are of about equal merit. The one introduced by Ahlfeld consists 
of tying with a sterile naval ligature 1 cm. from the skin of the abdomen and 
the severance of the navel cord about 1/2 cm. above it. Martin goes some- 
what further than this by applying a strong silk thread close to the skin 
around the cord and separating the cord about 1 to 1 1/2 cm. beyond. The 
cautery scissors employed by the latter author to prevent subsequent hemor- 
rhage have been proved by later investigations (Stolze) to be unnecessary 
provided the tying is done with the proper care and with the necessary pre- 
cautions. Both authors, Martin as well as Ahlfeld, accomplished this short- 
ening by two different tyings. The cord was first tied in the manner already 
mentioned and after bathing a second cutting of the cord to the measure 
previously indicated was made. Both claim as the advantage of this interval 
that the cord ontracts somewhat, the superficial layer dries, and a later 
loosening of the ligature is less to be feared. The increase of respiration due 
to the crying of the child in the meantime, as well as the greater progress 
of vascular contraction, is also of value. Upon the other hand this second 
operation has the disadvantage of doubling the danger of infection. The 
shortening to the required extent at once upon severing the cord certainly 
appears more advantageous. If the first tying is done provisionally by loops 
and in an hour is definitely fastened and two hours later, before leaving the 
patient, is examined again, the same purpose is attained. In my experience 
cases of subsequent hemorrhage have not occurred in recent years under this 
method. 

In speaking of the equality of the two methods this was meant to indicate 
particularly the definite results and the absence of any complication, especially 
of disease of the navel. As to the course, Martin's process seems to be some- 
what more favorable. Mummification of the stump of the cord and its de- 
marcation take place more rapidly, separation occurs sooner, and finally an 
earlier and more rapidly progressive retraction of the skin about the navel 
is noticeable. With Ahlfeld's method a broad, raw, granulating surface re- 
mains after the navel falls off and depression occurs only gradually. Briefly, 
in Martin's process the duration of healing is one to two days less. On the 
other hand, there are a number of reasons which make its general introduc- 
tion into practice less advisable. Ahlfeld showed that the silk ligature readily 
tears the tissue of the navel cord. Although, in comparison to the total 
number of cases, this was a very rare accident the possibility of such 



78 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

a complication must nevertheless be considered. Its occurrence is especially 
unfortunate as a further tying around the cord cannot occur and the ligature 
of the navel skin necessitates a decided prolongation of the healing process 
and with this an increase in the danger of infection. It is better, therefore, 
to tie so far from the skin of the navel that if necessity arises another liga- 
ture may be applied, therefore from 1 to 1 1/2 cm. distant, as was proposed 
by Ahlfeld, and to employ a broad (0.3 — 0.5 cm.) cotton band. The fact that 
with Ahlfeld's method the healing process is one or two days longer is of no 
great importance as the wound, provided it has been kept clean, is then 
covered with granulations which serve as a powerful protective wall to further 
infection. 

In addition to these methods of caring for the cord others have at times 
been attempted and advised (Peaudecerf, Kusmin, Keller, Dichenson, Porak, 
etc.). All modes of procedure have been proposed, from a careless division 
or squeezing without tying to the minutest closure by individual ligature of 
the navel vessels and a surgical knot of the cutaneous borders. While in the 
one the positive prophylaxis for eventual deleterious effects (hemorrhage) is 
absent, the others fail in other important requirements. All of them are 
more or less unsuitable for general practice and accordingly, after a short 
trial, have fallen into disuse. Their purely literary interest requires a further 
reference. 

For the subsequent treatment of the navel the Prussian Text-Book for 
Midwives requires the wrapping of the stump of the cord in lint or cotton 
smeared with vaselin. The latter prevents too great adhesion of the cloth or 
of the cotton with the cord and a removal of the dressing without injury to 
the navel wound is possible. As Runge showed experimentally, about 1880, 
by the employment of fat or oil the drying of the remains of the cord is 
essentially retarded and a predisposition to the accumulation of germs therefore 
correspondingly increased. Furthermore, an accumulation of secretion readily 
occurs around the point of separation of the cord and hence aids a possible 
infection. This is not likely to be overcome by the addition of antiseptics 
as their disinfecting action suffers greatly by being embedded in fat and oil. 
For this reason the use of antiseptic fat ointments in wounds of similar 
nature which leave necrotic tissue after demarcation has been abandoned and 
in the care of the navel by this means a warning rather than advice is in 
place. 

In many clinics the subsequent care of the navel occurs under the rules 
of pure asepsis, i. e., only sterile bandage material is employed, no antiseptics. 
This method is based upon the theory that, provided no unusual condition 
develops, the navel cord of the new-born at birth is free of germs, which was 
found to be correct by the bacteriologic investigations of Cholmogoroff. Theo- 
retically considered the careful management by pure asepsis would be suffi- 
cient and thus the best results be attained; but this is only practicable in 
the hands of a physician whose soul is permeated by the spirit of asepsis and 
who never forgets that the slightest error is liable to render every advantage 



DISEASES OF THE UMBILICUS 79 

illusory. The education of the nurse does not insure the required immunity. 
For this reason the treatment of the navel requires all the more consideration 
as the conditions for an accumulation of bacteria are much more favorable 
in consequence of the frequent contamination with urine than in wounds in 
other areas, and the change of the bandage which is so frequently necessary 
decidedly increases this danger. Finally, Cholmogoroff, even with a sterile 
treatment of the navel and in spite of normal mummification, was able after 
a few days to demonstrate pathogenic bacteria. From this it is evident that 
in private practice and in institutions, whenever the care of the navel is 
entrusted to the nurse it is better to employ antiseptics. Most useful for 
this purpose are substances which combine a drying process with their disin- 
fecting action. Both these properties are best fulfilled by alcohol. Ahlfeld 
uses alcohol after the bath and with every change of the bandage. I have 
followed his example for several years and am able positively to confirm his 
good results. The abdominal skin of the new-born bears alcohol well. The 
only precaution to be observed is that it does not come in contact with the 
external genitalia. Here, particularly in boys, it causes a decided edematous 
swelling. A permanent alcohol bandage, as is advised by Budberg, I do 
not consider necessary under normal circumstances. If, to aid mummifi- 
cation, the navel bandage is applied so that it admits the air the alcohol would 
evaporate very rapidly under the influence of the heat of the body. There- 
fore, to obtain a constant effect of the alcohol a more frequent change of the 
bandage or an air-tight covering is necessary, and both have proved to be 
unserviceable. In contrast to alcohol all of the watery solutions hinder drying 
on account of the addition of water. Besides, they do not enter so readily 
into all of the grooves and spaces. This is especially true of the pure disin- 
fecting fluids, and therefore corrosive solutions, proposed by Schliep for the 
early period before demarcation is complete or before the navel has fallen off, 
even when greatly diluted, are objectionable according to our present views 
as they prolong the entire process unnecessarily. Among the antiseptic pow- 
ders salicylic starch is most in use. At the beginning of the period of 
the antiseptic treatment of wounds the disinfecting action of salicylic acid 
was much favored, but on account of its slight solubility in the secretion of 
the wound it has deteriorated greatly in value. Still more unfortunate, as 
Rieck quite justly asserts, is the addition of starch, which by its tendency to 
crust formation readily retains the secretions in the space between the navel 
skin and the stump of the cord. The same is also true of clay, which has 
been advised as a dusting powder. The use of sugar might be of some value 
provided it could be obtained in a condition free from pathogenic germs, but 
actual disinfecting, bactericidal properties it does not possess. Of most 
service, according to many authors (Ahlfeld, Schrader, LeGendre, Varnier) 
are combinations of bismuth, especially of dermatol. In addition iodoform, 
sanoform, and itrol may be mentioned. 

The question now arises: How often, or when, shall the navel bandage 
be changed? With the knowledge that the greatest danger of infection is 



80 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

during demarcation, therefore before the navel falls off, and that it occurs 
by contact, the prophylactic appliance of an occlusive bandage during this 
period was considered for years. Tests were first made by Dohrn and later 
by Epstein, Eross and others. Aside from the technical difficulty to attain an 
absolute closure on account of the frequent discharge of urine, the results 
were less than satisfactory. In agreement with the previous experimental 
investigations of Runge softening and purulent decomposition were much 
more observed. Although this decided the question of a permanent bandage 
the idea of limiting the change of the bandage has been maintained by many 
authors to recent times. Such physicians have the infant bathed only once, 
directly after birth, and the bandage is not renewed except when contaminated 
with urine. Although the omission is only a means to an end, other authors 
go still further and designate the bath before the cord has separated as harm- 
ful and caution against its use. Delayed mummification, more ready softening 
of the stump of the cord, and especially infection from the bath if the water 
used is not sterile or if the tub is employed for other purposes, for example, 
for washing the pads of the mother, are the reasons which are particularly set 
forth. Some authors, in confirmation of their opinion, emphasize the effect 
upon general development: Children who are not bathed in the first days 
are said to lose less in weight and to gain earlier. Investigations in regard 
to the effect of the bath were undertaken by Anthes-Schrader in Halle, and 
by Czerwenka in Graz. The results were entirely opposite. Children who 
were not bathed presented a proportionately much greater contingent of 
pathologic changes: softening, decomposition, febrile diseases, etc. As to a 
gain in weight no essential difference was determined in the Clinic in Halle, 
while Czerwenka was able to report decidedly in favor of bathed children. 
As it is accordingly proven that with proper care all deleterious effects of 
bathing can be positively prevented, such a statement is rather theoretic than 
founded upon practice. Anyone may readily convince himself by his own 
observation that actual moistening of the surface of the umbilical cord only 
occurs for one or two days. Notwithstanding this the mummification usually 
proceeds unhindered. Later the water runs off as from an oiled bottle, drop- 
wise, a sign that with the drying there is associated fatty degeneration. The 
opportunity for the transmission of germs from the bath water is not serious 
and is only due to great neglect. In the investigations of Anthes-Schrader 
and Czerwenka the ordinary, non-sterilized water was employed. The prin- 
cipal danger lies in contamination by unclean vessels, which even among the 
poorest may readily be avoided. 

The proposition of Epstein and others to add to the bath prophylactically 
a mild antiseptic (potassium permanganate, etc.) is superfluous after what 
has been stated. Actual value from this method is scarcely possible as the 
great dilution of these already weakened substances necessitates a very long 
time to develop their effects. Furthermore the danger must not be disregarded 
that the nurse, having confidence in the disinfection, may neglect the neces- 
sary observation of strict cleanliness. 



DISEASES OF THE UMBILICUS 81 

Finally, an advantage of omitting the daily bath would be a less frequent 
change of the bandage. But even this is over-balanced by a series of dis- 
advantages. That bathed children flourish better has already been men- 
tioned. Furthermore, in the bath the wound is cleansed of the adherent 
secretion without contact, almost of itself. In contrast, the change of the 
bandage after contamination with urine acts as a trauma. Although Keil- 
mann maintains the opposite opinion probably no practitioner will agree with 
him. Then the wholesome effect of the bath upon the skin ! Frequent and 
vigorous * washing leads to intertrigo and hence produces new and no 
less serious ports of entrance for pathogenic microorganisms. Erysipelas, 
furunculosis, suppuration of lymph glands, phlegmons and, in girls, cystitis 
and pyelonephritis — pyometra, salpingitis — (Epstein) have been noted. By 
the desiccation of the cutaneous secretion, especially of the firmly adherent 
vernix caseosa, more or less circumscribed eczemas arise. In addition is the 
impression upon the laity and nurses, whose conception of cleanliness is 
embodied in the daily bath. To them the possibility of harm from this 
source is absolutely incomprehensible. Its omission will not be regarded as 
a stimulus for more caution and care in regard to cleanliness ; on the contrary, 
it will soon cause negligence. 

Therefore, with the necessary care the daily bath has nothing against it 
and much in its favor. In addition to the required change of the bandage 
after the bath it must be renewed whenever contaminated with urine. The 
long continuance of moist heat at the temperature of the body favors soft- 
ening and decomposition all the more when absorption and evaporation are 
prevented by a rubber cover. The purpose of the latter, to protect the crib, 
is fulfilled without any harmful effects if it has an opening in front, which 
is also a reminder to the nurse to substitute dry diapers for the wet ones. 

Particular care of the umbilical cord is necessary in the birth of twins, 
especially if the wound of one infant is infected. The most obvious precau- 
tions, care of the other child by another nurse and the employment of a 
separate bath-tub, can only be strictly observed in hospitals. In practice 
generally our only recourse is to attend to the healthy child always before the 
sick. In the interest of the former it is especially advisable not to bathe 
the latter, particularly if the illness is serious, although this hinders the 
transmissibility but little. In such cases regular washings with alcohol have 
always proved an excellent prophylactic. 

For the local treatment of the wound antiseptic measures are in place. 
With extensive superficial suppuration dry powder dressings with a mildly 
absorbent gauze are employed (boric acid, iodoform, dermatol), and with 
distributed inflammatory infiltration moist compresses with potassium per- 
manganate or acetate of aluminum. In cases of this kind an alcohol dress- 
ing in the form advised by Salzwedel has proved with me to be excellent and 
may be substituted by the dry dermatol applications when the symptoms 

1 The normal desquamation of the skin and mucous membranes of the newly born 
forbids " vigor " in the treatment of the surface and the mouth. — Editor. 

7 



82 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

begin to improve. Subcutaneous abscesses between the navel and the symphysis, 
and later in other areas, require early incision. Other reliable measures to 
prevent the further extension and development of general infection are not 
at hand. We are limited to a proper nutrition and perhaps analeptics to pre- 
vent a threatening disability. This applies also to those cases which already 
show the signs of a general infection. A trial of Crede's salve is certainly 
not contraindicated, ( ? — Ed.) but to the present time I have seen no brilliant 
results from its use. Antistreptococcic serum therapy is not yet so far ad- 
vanced as to justify confidence. Its trial, however, should not be neglected. 

In addition to septic general infection the navel wound of the new-born 
plays a very important role as a port of entrance for the bacilli of tetanus. 
The disease which results from this — trismus or tetanus neonatorum — has 
already been described in the chapter upon tetanus, and therefore, to avoid 
unnecessary repetition, I must refer to that article. 1 

Only with cicatrization of the cutaneous wound is the external closure of 
the navel completed. That of the actual navel ring, through which the vessels 
pass within the linea alba, takes place gradually toward the end of the first 
year. The tendency to hernia which results from this during the early 
period does not affect the cutaneous cicatrix, but, on the contrary, occurs 
above, between the outer circumference of the navel ring and the stump of 
the vessels. Formerly the fundamental cause of this peculiarity was referred 
to the energetic retraction of the vessels of the cord which are intimately 
combined with the cicatrix, particularly the arteries. According to Robin, 
in the course of time there is even a mutual displacement of the individual 
layers of the vascular walls, especially of the media toward the adventitia, 
which brings about the transformation into solid fibrous strands which are 
actually found a few weeks after birth in the vicinity of the navel. Herzog 
has demonstrated by exact anatomic and microscopic investigation that the 
entire process depends upon a transformation of the fetal cellular tissue 
into rigid connective tissue, to which is added an obliteration of the navel 
vessels and a degeneration of their walls into tense fibrous tissue with de- 
struction of the muscular elements. The incompleteness of the closure is 
a direct consequence of the original anatomic arangement, and is later in- 
creased by connective tissue contraction. As already mentioned the arterial 
strands possess a distinct, well-formed, broad adventitia which is in intimate 
connection with the tissues of the linea alba and of the navel ring, while the 
vein is only loosely layered in the upper portion of the latter without a sub- 
stantive adventitia. Although, accordingly, the transformation into rigid, 
coarse-fibered connective tissue causes the closure of the lower portion of the 
navel ring to be essentially firmer and more complete it must be added that 
the changes of the arterial strands begin at the navel and proceed toward 
the bladder. In the vein, the opposite direction is taken, from the liver to 
the navel. Within the abdominal walls the venous vessel is immediately ad- 
jacent to the arterial strands. The stronger and earlier contraction of the 

1 See volume on "Infectious Diseases." 



OTHER SOURCES OF SEPTIC GENERAL INFECTION 83 

latter, therefore, must produce a corresponding dislocation of the former and 
approximate it to the lower circumference of the navel ring and remove it 
from the upper. In this manner there develops between the upper circum- 
ference of the navel ring and the remains of the vein a point of least resist- 
ance. This space, known as the umbilical canal, which is filled with loose 
cellular tissue, is closed peritoneally only by a narrow layer of connective 
tissue and externally by the skin. Great exertion of the abdominal press 
(screaming, vomiting, pressing, coughing, etc.) may readily protrude the in- 
testines and lead to hernia, preventing a definite closure. Prophylactically, 
in the first three months it is always advisable to provide a certain amount 
of support for the navel by the employment of a bandage with an underlayer 
of cotton. For the treatment of navel hernia the application of an adhesive 
plaster bandage over a firm plate was formerly the preferred method; now 
injections of paraffin will probably be used. 



OTHER SOURCES OF SEPTIC GENERAL INFECTION 

In the foregoing it has been shown that infection of the umbilical wound 
is the most common source of septic general infection of the new-born. In 
addition, there are other ports of entrance. Any external injury to the 
child may be subject to a similar fate and course. For this reason in the 
pre-antiseptic period pressure marks, etc., were greatly feared. Naturally, 
contamination may occur as readily post partum as intra partum since the 
same instrument, the hand, may produce the injury and infection. In the 
subsequent days of life these tissue spaces associated with intertrigo become 
serious. Their various mild and severe sequels have already been mentioned. 
The cutaneous changes of congenital syphilis also belong in part to this 
category. Finally, as in the adult, streptococci may permeate the exits of 
the glandular ducts, lead to a local septic inflammation, and be transmitted 
thence to the rest of the body. 

A second path has its starting-point in various portions of the digestive 
tract. The oral cavity and the anus are chiefly predisposed since they are 
most frequently subject to direct contact. The careless introduction of the 
thermometer into the rectum, or of the nozzle for an enema, may be the 
immediate cause, and in the oral cavity unskillful washing is the most com- 
mon. Apart from the delicate composition of the- oral mucous membrane 
the marked desquamation which occurs within the first few days of life 
favors the development of superficial injuries. Through the limitation 
which cleansing of the mouth at birth has undergone in the last decades the 
influence of this source of infection has been greatly decreased. In relation 
to other portions of the digestive system the composition of the food must 
be considered. P. Miiller was the first to voice the suspicion that puerperal 
infection of the mother may be transmitted to the child through the milk. 
At first bacteriologic investigation seemed to confirm this view. In the 



84 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

puerperal lying-in woman the milk contains staphylococci (Escherich, Kar- 
linski) ; normally it is always sterile (Meissner). Bumm demonstrated cases 
in which the milk of the septic lying-in woman, notwithstanding repeated 
and minute investigation, was found free of germs, and Cohn and Neumann 
were able to cultivate bacteria and staphylococci from the milk of a healthy 
mother which probably had permeated from without into the gland. There 
is a possibility that germs may be transmitted to the child with the milk; 
nevertheless it has been practically proven that the milk of the septic mother 
may be taken by the child without injury (Runge, Wolff, Schutz, Biedert, 
etc.). A healthy digestive apparatus is therefore uninfluenced and only 
reacts to the smaller number of bacteria which come into consideration when 
diseased. 

Septic microorganisms may also gain access by way of the respiratory 
tract. By aspiration of decomposed amnionic liquor or of the maternal 
genital secretion intra partum in premature respiration septic pneumonia 
may develop from which the child perishes soon after birth. This occur- 
rence, however, is not frequent. Most children perish intra partum in con- 
sequence of severe complications; others born alive show only transitory 
catarrhal changes or remain perfectly well. For the differential diagnosis 
it is important to know that this is also the most frequent localization in the 
metastatic inflammation of umbilical sepsis. Here, apart from the corre- 
sponding symptoms in the mother the early development, even before the 
loosening of the umbilical cord, is decisive. Another means of transmission 
by way of the respiratory tract is by inhalation. Experimental investiga- 
tions are but little conclusive on account of the overloading of the respired 
air with septic germs and the manner in which they were introduced in the 
experiment. It must also be remembered that the infective products had 
previously found sufficient points of deposit on account of the predominantly 
nasal respiration of the infant. Erom here, it is true, the process may grad- 
ually distribute itself further and deeper. Highly interesting and conclu- 
sive in this connection are the reports of an epidemic of septic pulmonary 
disease in the new-born reported from the Heidelberg Obstetrical Clinic by 
Gartner, which he traced bacteriologically to infection from damp straw 
bedding. Such a process of distribution, however, is the rarest and usually 
beyond our intimate recognition. 

Among the older authors the transmission by the placenta is assigned 
a great role. Although, in comparison to former times, this possibility has 
lost greatly in importance on account of the further development of the 
law of wound infection and especially of septic general disease, it cannot yet 
be altogether rejected. Among the cases which have been published only an 
observation of Orth^s will stand the most exacting criticism in every detail. 
The necessary prerequisite is a corresponding disease of the mother during 
the puerperal period or at the latest intra partum. The fetus is still-born 
or perishes soon after birth. With the positive exclusion of all other sources 
of infection, especially on the part of the navel, the autopsy must reveal the 



DISEASES OF THE EYES 85 

evidences of sepsis. The rarity of septic disease of the mother during preg- 
nancy or parturition is due to prophylaxis. [The researches of Warthin, 
of Ann Arbor, on the transmission of tuberculosis through the placenta 
were not known to the author. — Editor.] 



DISEASES OF THE EYES 

GONORRHEAL INFLAMMATION 

The eyes, like the navel, require careful attention after birth. The inti- 
mate contact of the palpebral fissure and its immediate surroundings with 
the maternal genital walls and with the adherent secretion, after the rup- 
ture of the fetal membranes, is the means of an infectious transmission 
which is all the more possible the slower the birth of the head. All patho- 
genic microorganisms in the maternal genital apparatus come under con- 
sideration, no matter under what circumstances they may be present. Most 
common and most serious is Neisser's gonococcus. Exceptionally the inva- 
sion occurs so early that the infant is born with inflamed eyes. Krucken- 
berg, Feiss, and others have reported cases in which the specific character 
was confirmed hy the demonstration of gonococci. No less often the disease is 
observed within the first twelve to twenty-four hours. The intrauterine on- 
set is here less certain, for according to experimental inoculation tests 
(Bumm) and in the individual phases in which infection occurs in adults 
there is a possibility of an incubation within a few hours. In by far the 
majority of cases the first signs are noted from the third to the fifth day. 
The explanation of this apparent delay is that the infectious secretion at 
first merely adheres to the external surface of the lids, the eyelashes and the 
borders, the internal and external canthus, and only enters the conjunctival 
sac later, when the eyes are opened, or by unskillful and particularly wet 
cleansing. According to the maximum period of incubation of gonorrhea a 
later affection can only be assumed by another form of transmission (fingers 
of the mother or nurse, unclean bedding, bed-clothes, sponges, bath water, 
etc.) whereby the germ-containing material may be transmitted from the 
mother, as well as from another child with diseased eyes or from any indi- 
vidual suffering from gonorrhea. Clinically the consequences are first re- 
vealed by an ordinary catarrhal inflammation. The palpebral space is 
slightly agglutinated. When it is opened a profuse, thin, turbid secretion 
containing numerous flocculi is discharged, often with a certain amount of 
force, in a stream. The conjunctiva is greatly reddened and swollen, espe- 
cially in the region of the conjunctival fold. In the course of hours these 
inflammatory changes are rapidly increased. The eyelids, especially the 
upper, are reddened externally, with edematous swelling. The eye is always 
closed. The rigidity of the lids makes the opening of the palpebral space 
difficult. From there a thick, mucopurulent, whitish-yellow secretion oozes, 
the removal of which reveals the deep red conjunctiva with velvety swelling 



86 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

and marked infiltration, and upon widening of the fissure new rolls constantly 
protrude. At first nothing can be seen of the bulbus. An accurate view is 
only possible by completely inverting the eye-lids. The marked changes 
are localized to the conjunctival fold. The conjunctiva \>ulbi is also in- 
volved and forms a wall-like prominence around the cornea. With the 
transformation of the secretion to a purely purulent character there is in a 
few days a gradual decrease of the rigid swelling. The lids become softer, 
the conjunctiva looser. In the region of the conjunctival fold the tendency 
to wrinkles is noticeable and in the tarsal portion papillary proliferation is 
particularly apparent. The secretion, previously abundant, decreases, gradu- 
ally assumes a mucous character, and finally ceases. The fold-like and 
papillary proliferations may disappear without causing cicatrization. The 
duration of the disease varies between two and eight weeks. With a pro- 
longation of the final purulent stage, however, it may assume a chronic 
character and recovery may be retarded for months. 

Pathology. — Pathologico-anatomically gonorrheal conjunctivitis is not 
a surface affection. Here as in the genital apparatus the gonococci actively 
invade the epithelial layer by way of the cement substance to the subepithe- 
lial connective tissue. Bumm was the first accurately to investigate the in- 
dividual phases of this process, which he has published in an explicit article. 
Upon the second day the epithelial layer may be completely permeated with 
diplococci. The immediate consequence is a correspondingly rapid and great 
inflammatory reaction of the vascular connective tissue (hyperemia, serous 
and cellular exudation). Vast swarms of white blood corpuscles collect in 
the superficial layers and permeate the epithelial cover to the surface. By 
this means the epithelial layer, which has been previously loosened by the 
invasion of bacteria, becomes still more relaxed or raised. At the limbus 
corneae and on the border of the lids this process is sharply demarcated. 
The transitional epithelium remains uninfluenced by the action of the bac- 
teria and its appearance is unchanged. After breaking through and loosen- 
ing the epithelial layer the gonococci distribute themselves in long or short 
chains or round colonies and also to a certain extent within the superficial 
connective tissue layer. A deeper permeation is rarely observed and in form 
and course greatly resembles pre-formed lymph spaces. Under the influ- 
ence of these microorganisms the inflammatory symptoms are greatly in- 
creased. The round-cell infiltration may finally extend 2 mm. below the 
surface and is so dense that cell approximates cell. The blennorrhea has 
passed into the purulent stage. 

Aside from the decrease of gonococci and the cessation of the irritative 
symptoms in the connective tissue of the mucous membrane the commence- 
ment of healing is characterized by the beginning regeneration of the sur- 
face epithelium. This covering, at first consisting merely of a simple layer 
of cubic or flat cells, by the rapid proliferation of the elements soon reaches 
a thickness of two or three layers, the uppermost being subject to a gradual 
deposit of epidermis. During the new epithelial formation the emigration 



DISEASES OF THE EYES 87 

of the white blood corpuscles continues without any disturbance of the regu- 
lar arrangement. With its completion the papillary body is entirely free of 
gonococci, which may only be found superficially between the individual 
epithelial elements. Renewed infection and accidents may interrupt and 
prolong the uniform progress of healing. In the third week of the disease 
the epithelium is usually intact. The entire conjunctival sac is finely 
clothed by layered pavement epithelium which is substituted by cylindrical 
epithelium after complete disappearance of the swelling and proliferation 
of the papillary bodies. 

The principal danger of this affection, which is usually designated oph- 
thalmoblennorrhea, gonorrheal conjunctivitis, or blennorrhea neonatorum, 
depends upon the transmission of the inflammation to the cornea. Superficial 
desquamation of epithelium in the region of the palpebral fissure, especially 
near the border of the cornea or below its middle, is by no means rare. So 
long as the process remains thus limited a subsequent damage is excluded. 
The early superficial turbidity is only transitory and finally disappears com- 
pletely. Through these epithelial defects, however, the way is open for the 
generators of inflammation to the interior of the eye. Infiltration of tissue 
occurs and the necrotic destruction causes ulceration. If this remains within 
moderate bounds and soon yields to cleansing and healing the resulting cica- 
trization causes a corresponding turbidity of the cornea (leukoma), which 
decreases in intensity and extent with advancing age, but nevertheless, from 
its position in the pupil and its circumference, may cause a more or less de- 
cided impairment of sight. If the necrotic process continues, perforation of 
the anterior chamber of the eye is inevitable and is followed by further in- 
jury: prolapse and adhesion of the iris (leukoma adherens, partial or com- 
plete staphyloma), anterior capsular cataract, protrusion of the lens and a 
part of the vitreous body with succeeding atrophy of the bulbus; or, by a 
distribution of the process to the interior of the eye a panophthalmia occurs. 
Thus there may be any stage of impairment of vision to complete blindness. 

From the conjunctival sac the gonorrheal catarrh may pass to the nasal 
mucous membrane and from there distribute itself to the internal ear (gonor- 
rheal otitis media). Diseases of the oral cavity, occasionally observed simul- 
taneously with gonorrhea of the eye, may accordingly be referred to a sub- 
stantive transmission, either during birth or, more readily, later by the 
hands of the nurse or of the mother, by mouth swabs, etc. Nevertheless, the 
possibility cannot be excluded that a germ-containing secretion from the 
eye may flow over the face into the mouth. 

Constitutional affections characterized by the appearance of remote meta- 
static inflammatory foci in connection with a primary gonorrheal conjunc- 
tivitis are comparatively rare in the new-born. Here also the large joints, 
especially the knee, are most often affected. The acute onset (sudden, 
marked, sensitive swelling with fever) later passes into a prolonged chronic 
course. The tendency to suppuration and anchylosis appears to be decidedly 
greater than in a corresponding condition in adults. Similar!}', periarticular 



88 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

arthritic inflammation in the cavity of the joint, without exudation, and 
tendovaginitis may lead to motor disturbance. Finally, endocarditis must 
be mentioned — the severest but also the rarest complication — whicli usually 
occurs in association with gonorrheal rheumatism and only exceptionally 
alone, the clinical symptoms corresponding in the main to those of the adult 
form. [The small joints, mainly of the hands, also the cervical lymph bodies 
connecting with the nares and the mouth with consecutive general pyo-sep- 
ticemia, may be met with. — Editor.] 

Diagnosis. — The diagnosis of gonorrheal ophthalmoblennorrhea depends 
upon the bacteriologic examination of the secretion, for which a simple 
smear preparation is sufficient. In addition to the characteristic diplococcus 
form, described by Neisser as bun-shaped, the arrangement into small and 
large colonies within the cell protoplasm is important. The number of gono- 
cocci present varies greatly in different cases and is not actually proportionate 
to the degree of the local inflammatory condition. In severe blennorrhea 
they are often scant, in the milder forms numerous. The observation is also 
of importance that the bacteriologic investigation may occasionally be posi- 
tive after a decided decrease of the final catarrhal symptoms; therefore trans- 
mission even then cannot be altogether excluded. 

Prognosis. — The prognosis depends in general upon the complications. 
Although doubtful without these it is essentially improved by the early insti- 
tution of proper treatment. Nevertheless, it is well not to be too sanguine, 
for notwithstanding all precaution and proper care eventual blindness has 
been observed. Essentially important are the general nutrition and the de- 
velopment of the child: In debilitated, premature infants and those enfeebled 
by digestive disturbances an affection of the cornea cannot always be pre- 
vented. 

Treatment. — For prophylaxis we must differentiate between transmission 
at birth and that occurring subsequently. The former may be counter- 
acted during pregnancy by antiseptic measures. Tamponage of the vagina 
with gauze saturated in a 1 to 1,000 solution of corrosive sublimate twice 
every week for five or ten minutes has proven in my hands more advanta- 
geous than injections. By this means we best succeed in penetrating the 
numerous folds and creases. Silver nitrate solutions even when greatly di- 
luted produce marked irritative phenomena and are painful during preg- 
nancy. More suitable are the organic silver salts, such as protargol, etc., 
which have a weaker action. Directly after birth the best prophylactic, pro- 
posed by Crede in 1881, is the dropping of a solution of silver into the con- 
junctival sac, which to-day is recognized by all authors as the only positive 
and reliable method. The statistics of some of the obstetrical institutions 
are particularly convincing. Previously from 9 to 15 per cent., and in the 
last decades of the last century sometimes as high as 50 per cent. (Haase), 
the morbidity after the introduction of Crede's method fell as low as 0.8 per 
cent. Unfortunately the early optimism that ophthalmoblennorrhea could 
thus in time be completely rooted out proved to be premature according to 



DISEASES OF THE EYES 89 

the later compilations from blind asylums. According to Cohn's report, 
within fifteen years (to 1895) there was a decrease in the blindness due to 
blennorrhea to 19 per cent., from 30 per cent, in former periods. In 1902 
a similar report was made by Hirsch, who found that 12 per cent, of the 
cases of blindness in adults and 18 per cent, in adolescents were due to 
blennorrhea. These comparisons only consider total blindness. For a com- 
plete summary the cases of unilateral blindness and partial impairment of 
vision should be added, which would considerably diminish the difference. 
The comparatively slight success of the method in general practice is readily 
explained by the fact that 95 per cent, of all births (in Germany) occur not 
only outside of institutions but even without a physician. It is true that in 
the Prussian directions to midwives since 1892 Crede's method is demanded 
for women who " suffer from a contagious vaginal discharge." But in addi- 
tion to the fact that the midwife is not capable of deciding this question there 
are also gonorrheal infections, especially of the mucous membrane of the 
cervix, in which the secretion from the vagina, which is always present in 
pregnancy, is not materially increased. The modification of the directions 
to read " with a purulent discharge," as is contained in the Bavarian law, is 
but little better. A change in general practice can only occur by relieving 
the midwife of responsibility and the obligatory introduction of Crede's 
method. The objection raised by some authors on account of subsequent 
consequences in non-infected children (silver catarrh) is overcome of itself, 
for even these authors admit that the development of such a condition may 
be due to an unskillful application of the method; therefore, with sufficient 
instruction this can be excluded. The obligatory introduction might at 
least be made dependent upon the permission of the father, whose refusal 
would relieve the nurse of responsibility [and the baby of blindness? — 
Editor]. So long as there are no definite rules physicians may do much to 
improve the condition. Here also, as has already repeatedly been emphasized, 
the fundamental principle is that the professional interest and behavior is 
a guide to the nurse for her commissions and omissions. If the physician, 
in a labor occurring under his direction, attaches value to the employment 
of Crede's method, the nurse when away from his supervision will be less 
likely to neglect it than in the inverse case, when she will suppose it to be 
superfluous. A favorable opportunity thus arises to teach the nurse the 
method or to show her the correct procedure. The custom of some practi- 
tioners to make the treatment dependent upon the positive report of the 
parents is not reliable, as untruthful statements are by no means unusual 
from a false sense of shame or ignorance of the serious consequences. 

The method advised by Crede consists of the instillation of a drop of a 
2 per cent, solution of silver nitrate. For accuracy his directions will be 
given verbatim: "After the cord has been tied, the child bathed, and the 
eyes wiped with a clean cloth and sterile water — not bath-water — until all 
cutaneous mucus adherent to the lids has been removed, and before the child 
is dressed, an instillation should be made. By means of two fingers each 



90 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

eye is partially opened and a small drop of a 2 per cent, solution of silver 
nitrate, dependent from a glass rod, is brought in contact with the cornea 
and let fall upon the middle of the structure. All further treatment of the 
eye ceases. If in the next twenty-four or thirty-six hours a slight swelling 
or redness of the lids with excretion of mucus should result the instillation 
is not to be repeated. The glass rod should be 3 mm. thick, with rounded 
ends and smooth. The silver nitrate solution must of course be kept in a 
dark bottle with a glass stopper. The supply should be as small as possible 
(about 15.0)." * 

It is important that the first superficial cleansing should not be done 
with saturated cotton, but with sterile cotton wrung from boiled water; 
otherwise the secretion, laden with microorganisms, may easily be flooded 
into the conjunctival sac. Instead of the glass rod a pipette is now in gen- 
eral use. The danger that several drops may be instilled and cauterize too 
severely may be avoided with practise. The point of instillation — the middle 
of the cornea, corresponding to the middle of the conjunctival sac and near 
the point of first involvement in the palpebral space — also appears to be im- 
portant. The frequency of marked irritative phenomena, the so-called silver 
catarrh, which was observed by Cramer contrary to all other authors, may 
probably be explained by his special and more irritating technics Cramer 
dropped the silver solution into the internal angle of the eye, then opened 
the lids, directed the solution over the eye by a lateral inclination of the 
head, and distributed it in the conjunctival sac by closing and opening the 
lids. His caution against Crede's method has in this way been explained 
and rejected by Leopold. The same antiseptic effect that is produced with 
a 2 per cent, silver nitrate solution occurs with a 1 per cent, solution, but 
with slighter secondary irritative phenomena. Eunge, Gusserow, Fehling, 
Hofmeier, Leopold, and others have tested its employment extensively and 
obtained excellent results. After a practical experience of about ten years 
I can confirm this opinion and would advise the modification of Crede's 
method in practice. Watery solutions of silver nitrate become more con- 
centrated after long standing by the gradual evaporation of the water and 
cause greater cauterization and more marked irritation. In city practice 
this disadvantage is readily overcome if the solution is always freshly prepared. 
The fulfillment of this precautionary measure in obstetrical practice in the 
country is more difficult and its observation by midwives can scarcely be ex- 
pected. Zweifel therefore substituted silver acetate, which only dissolves 
to 1 per cent, at the temperature of the room, and with further evaporation 
throws down the precipitate. To prevent a marked corrosive action subse- 
quent washing with a normal salt solution was tried. The prophylactic 

1 History repeats itself, also the neglect of its teachings. Exactly fifty years be- 
fore Crede, Eisenmann — the same who was left in a dungeon twelve years by one of 
the trembling and rancorous German rulers — the founder of what is best known as 
Virchow and Hirsch's annual reports, recommended besides absolute cleanliness the use 
of a mild chlorine water. Nobody followed his advice, the babies got blind as before, 
and the blind asylums " profited." — Editob. 



DISEASES OF THE EYES 91 

result has also been recognized by other authors (Tauffer, Hofmeier, etc.), 
but the absence of irritation has been contradicted. The same is true of the 
20 per cent, solution of protargol (Zweifel) recommended by Engelmann 
and later by Piotrowski and Veverka, and weaker concentrations have 
proved unreliable. In addition to these reagents quite a number of others 
have been tested — salicylic acid, carbolic acid, chlorin water, potassium 
permanganate, iodoform, /?-naphthol, resorcin, thymol, iodin trichlorid, 
zinc sulphocarbolate, corrosive sublimate, mercury citrate, ethylidenediamin 
— but upon subsequent investigation have been found to be less serviceable 
in prophylaxis. Therefore, the experience of syphilographers and ophthal- 
mologists regarding the specific action of the salts of silver upon gonococci 
seems to be confirmed. 

For the prophylaxis of transmission in the days subsequent to birth the 
same rules are operative as have already been explicitly detailed for the pre- 
vention of navel infection; therefore scrupulous cleanliness on the part of 
the midwife, nurse, and mother, which applies to the hands as well as all 
articles which come into close contact with the eye! Beware of sponges; 
fresh absorbent cotton should always be used! Strict observation in regard 
to cleanliness of the bath-tub and particularly that it is not employed for 
washing the pads of the mother ! Care of the child always before attention 
to the mother! The mother should have the child in bed only for nursing, 
and invariably before she takes the child her hands should be thoroughly 
washed. Finally, when gonorrhea is present the mother and the nurse 
should be expressly instructed in regard to the danger of transmission to 
the child as well as to themselves and to those about them. 

If one eye is already infected the first requirement is to prevent the other 
from a secondary infection. Besides the observance of general rules the 
head of the child should be placed upon the diseased side, the hands tied, 
the normal eye cleansed always before the other, and the diseased eye wiped 
from within outward, which is most positively accomplished by the appli- 
cation of an occlusive bandage: cotton, gauze pad fastened with collodion or 
cotton, gutta percha tissue fastened by means of chloroform. This bandage 
must be removed twice daily to note whether the eye has become infected and 
is then renewed immediately. Some authors also advise the periodic instilla- 
tion of 1 per cent, silver nitrate solution. 

The beginning of local treatment of the diseased eye had best be expect- 
ant and limited to the avoidance of any great accumulation of secretion by 
its frequent removal and by mild disinfection of the conjunctival sac. 
After cleansing the external surface and with the palpebral space somewhat 
open the lids are ectropionized and the conjunctiva cleansed by means of 
cotton or a gauze compress. The fluids employed for disinfection are the 
milder agents — boric acid, 2 to 3 per cent., hydrochinon, resorcin, etc. — also 
dilute solutions of stronger disinfectants — corrosive sublimate 1 to 5000, 
mercury oxycyanid 1 to 500, iodin trichlorid 1 to 4000, potassium perman- 
ganate 1 to 3000, silver nitrate 1 to 1000. This process of ectropionization 



92 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

appears less irritating to the conjunctiva and particularly to the cornea Hum 
the method of distributing the fluid over the eye by friction of the eyelid. 
Careful cleansing by this means should be done at least twice daily. In the 
interval, every thirty minutes or an hour, the eye is washed externally 
with slight separation of the lids. In this stage the application of cold is 
advantageous in the form of cotton or gauze compresses moistened with one 
of the above disinfectants and cooled upon ice, and changed every three to 
five minutes. All bandage material should be burned after use. When the 
secretion has assumed a purulent character and the swelling of the lids has 
decreased to the extent that the eyes open voluntarily, usually from the 
third to the fifth day, a caustic astringent treatment may be begun. In se- 
vere cases the silver nitrate pencil is employed, in milder forms a 1 or 2 
per cent, solution of silver nitrate (painting of the ectropionized lid, or in- 
stillation), and the superfluous amount of silver nitrate subsequently removed 
by a solution of salt. After the cauterization the application of cold for a 
few hours is advisable. This treatment is continued daily and later, when 
the secretion ceases, every second day, perhaps with a diluted solution. 
Complete cure usually requires from three to four weeks. The treatment is 
the same if the cornea is involved except that greater caution is necessary 
and especially that all pressure upon the eye must be avoided. To diminish 
the consequences of a possible perforation the instillation of atropin or phy- 
sostigmin (eserin), according to the seat of the ulceration, is employed. To 
enter minutely upon the special treatment of the further complications would 
lead us too far. In the consideration of these questions we must refer to 
text-books upon ophthalmology. 

OTHER PATHOGENIC MICROORGANISMS 

Thus far we have considered only gonorrheal inflammation of the eye 
in the new-born. Minute bacteriologic investigation of the secretion of the 
eyes, which has become the rule in the last decades, especially in diseases of 
the new-born, has revealed that in addition to Neisser's gonococcus not in- 
frequently other pathogenic microorganisms (streptococci, staphylococci, 
pneumococci, diphtheria bacilli, diplobacilli, Koch-Week's bacilli) have been 
found in such numbers that the view of a mixed infection is fully justified. 
Although, according to the result of experimental investigation, we ascribe 
to the gonococcus in these cases the main part in the deleterious consequences, 
ophthalmologists have recently published a series of cases in which gonococci 
were absent (Schmidt-Rimpler, Axenfeld, Chartres, Eeyling, Groenow). 
In some of these cases it was demonstrated that the above-mentioned varie- 
ties, either alone or in combination, were the cause of the affection. The 
rarity with which infectious processes, due to the transmission of such patho- 
genic germs, are now observed in the mother at the time of delivery, and the 
greater rarity of the birth of a living child under such pathologic conditions 
are the reasons that the transmission to the conjunctival sac intra partum is 



LOCAL DISEASES 93 

exceedingly exceptional; therefore it must occur later, in the care of the eyes 
by the nurse or the mother. The clinical course of these non-gonorrheal 
affections of the eye shows a number of peculiarities which perhaps may es- 
cape the first investigation but become noticeable after prolonged observation. 
The local irritative phenomena remain within essentially narrow limits. An 
actual blennorrheic stage of profuse pus secretion is either absent or at 
most is suggested. The duration of the disease is decidedly shorter and is 
much more rapidly influenced by proper treatment. A tendency of trans- 
mission to the cornea is exceedingly rare. Therefore the prognosis with 
timely treatment is essentially better and the question of prophylaxis is al- 
ready answered by what has been stated. The treatment agrees fundamen- 
tally with that of the gonorrheal disease: Disinfection in the florid stage 
for the discharge of the secretion, and later the employment of caustic 
measures. With an abbreviation of the first phase, however, the latter treat- 
ment begins much earlier. 

Finally, there is a third group of inflammations of the eye in the new- 
born in which the bacteriologic investigation of the secretion has given a 
negative result. It is true that microorganisms have been found, but either 
they were not pathogenic or were present in such small numbers that etio- 
logically they could scarcely be considered. Nevertheless our investigations 
regarding the pathogenicity of bacteria in the conjunctival sac are not to be 
looked upon as conclusive. I need only refer to the coli bacteria, the influ- 
ence of which probably is not quite so benign and, in the new-born particu- 
larly, play a great role, since they are found in the feces in almost pure 
culture and an external transmission on the part of the nurse is readily 
possible. An additional cause of development may be the result of chemical 
and mechanical lesions. As an example of the former silver catarrh has been 
mentioned. With careless nurses contamination by urine and feces may come 
under consideration, as well as the entrance of soap while bathing, more or less 
decomposed milk, etc. A mechanical cause may result from the zeal of 
the nurse in cleansing the eyes and producing an injury. The infantile 
eye reacts much more strongly and readily to all of these influences than 
that of the adult, because the protective mechanism, the ebb and flow of the 
tears upon opening and closing the eyes, has not yet begun to function 
and the eyes are usually closed. Clinically these forms as a rule belong to 
conjunctival catarrh and with the proper treatment they rapidly heal. The 
prophylaxis consists of the early care and cleanliness of the nurse which has 
so often been described. 



LOCAL DISEASES 

As the diseases of the mucous membrane of the mouth and the method 
of care of the mouth, as well as the nutrition of the child and the digestive 
disturbances, are explicitly described in other parts of this work, among the 



94 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

local diseases it is only necessary for us to consider vulvo-vaginitis, mastitis, 
and intertrigo. 

Vulvo-vaginitis. — This is rare in the first days of life. Its development 
is almost invariably due to gonorrheal infection, which very exceptionally 
occurs intra partum, but is usually later, in the care of the child by the 
nurse. The diagnosis depends upon a thick, purulent secretion, which is 
soon noticeable, and its bacteriologic constituents. To prevent further dis- 
tribution energetic measures are necessary provided other infection (eye, 
mouth) is absent. Therapeutically most authors advise douches with cor- 
rosive sublimate, 1 to 5000, or with silver nitrate, 1 to 2 per cent. I have 
usually limited myself to washing the entrance and the surrounding parts 
with a corrosive sublimate solution, subsequent dusting with a readily drying 
powder (dermatol, etc.) and the external application of a quickly absorbent 
gauze. In this manner the few cases I have seen were speedily cured. 

Mastitis. — The development of this affection occurs in the new-born 
similarly as in the lying-in woman. After birth and usually from the third 
or fourth day the mammary gland in every newly born child is physiologi- 
cally subject to an increase of function. It enlarges more or less and be- 
comes more distinct, harder, and apparently also more sensitive, exception- 
ally reaching the size of a walnut or larger. Simultaneously there is a 
secretion of fluid chemically as well as microscopically identical with mother's 
milk (witch's milk or colostrum). This physiologic period of lactation re- 
mains for a short time at its acme and usually disappears after three or 
four days, when the breast returns to its previous condition. By frequent 
squeezing and pressing, as was formerly in vogue, this lactation is prolonged 
and may be kept up for months. During this physiologic irritative con- 
dition the breast is predisposed to infectious processes, just as in adults. 
Without further inducement streptococci and staphylococci may permeate 
deeply under the surface by way of the milk passage and cause inflammatory 
changes and even suppuration. Naturally, this possibility is greatly en- 
hanced the longer the period of lactation, or, if artificially protracted, the 
more the glandular tissue is disturbed in its activity by compression. 
Prophylactically, therefore, it is necessary to leave the gland alone and to 
attend to the necessary cleanliness of the skin and clothing of the child. 
Direct treatment for the process of lactation, which is entirely physiologic, 
is unnecessary. With decided redness and swelling, or when the signs of 
infectious inflammation have appeared, mild inunctions of Crede's ointment 
or gray salve may relieve the process. But, as in the adult, this rarely suc- 
ceeds. The application of an ice-bag is not advisable on account of the ex- 
treme sensitiveness of the skin of the new-born, particularly to cold. Priess- 
nitz compresses and prompt incision most rapidly retard the inflammatory 
process. The occurrence of suppuration is not always characterized by a 
rise in temperature. In severe cases the inflammatory infiltration may pass 
from the gland to the surrounding tissue (perimastitis) and finally reach 
the axillary cavity. As with every other phlegmon a general sepsis is pos- 



LOCAL DISEASES 95 

sible and cases of this kind have been reported. Furthermore, a circum- 
scribed disease of the gland may eventually lead to contraction, whereby 
lactation in womanhood readily becomes impossible. By improper incis- 
ion [it should be radiated, in a line leading away from the nipple. — Editor.] 
or a rigid retraction of the cicatrix distortion of the nipple may occur, analo- 
gous to congenital depressed nipple, and lead to a later incapability of use. 

Intertrigo. — Intertrigo is a chronic, oozing eczema of the skin in the 
areas of folds. In addition to the buttocks and the region behind the ear, 
in children with much adipose tissue the throat, neck, and the flexors of the 
joints are particularly predisposed. The inflammatory change is not always 
limited to the folds of the skin, but is often distributed to the surrounding 
area and may sometimes involve a large portion of the surface of the body. 
The affected part appears more or less reddened and infiltrated, and the 
surface oozes or is covered with crusts. Peripherally to the inflamed sur- 
face or within it, where the epidermis is still retained, papillary elevations 
and vesicles filled with serous fluid are found. In the depths of the folds 
painful fissures appear, and infection causes a development of pustules in 
the surroundings. 

The ultimate cause of intertrigo depends upon external mechanical or 
chemical irritation. The infantile epidermis after birth is comparatively 
delicate and but little resistant. [And undergoes a normal desquamation. — 
Editor.] The region of the buttocks is endangered by reason of the neces- 
sary cleansing if it is not carried out with the proper care and caution: 
The skin is very easily injured by rubbing. Chemical irritation arises in 
consequence of decomposed urine (infrequent change of the diapers, a close 
rubber cover), or, in digestive disturbances, from the strongly acid reaction 
of the diarrheic discharges. Similar conditions affect the folds and creases 
upon the neck, nape of the neck, and the joints, except that here the re- 
tained secretion of the skin is subject to decomposition. Vomited material 
which flows down the neck, if not carefully removed, may also cause the con- 
dition. 

Intertrigo, like every chronic eczema, is merely a local disease. Con- 
stitutional symptoms are not present. Nevertheless, we must assume that 
in the new-born, as in adults, chronic eczema, particularly of the anus and 
genitalia, in consequence of repeated irritation from contamination with 
urine is associated with sensitiveness and therefore with increased restless- 
ness, sleeplessness, etc., by which the infantile organism may be debilitated. 
The danger of septic infection has already been mentioned and its conse- 
quences explained. 

Prophylactically all irritation must be avoided: therefore scrupulous 
cleanliness, careful removal of the bath-water and secretion of the skin from 
the folds, frequent change of the diapers. On account of the constant wet- 
ting and contamination the region of the buttocks should be anointed (vase- 
lin) and afterwards powdered. Digestive disturbances and diarrhea are to 
be prevented by a proper regulation of the diet. 



96 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

Therapeutically Hebra's treatment by salves and powders is the most 
effectual. Vaselin is preferable to lanolin, byrolin, etc., on account of its 
insolubility in water. These substances are used either alone, by inunction 
of the affected regions and subsequent dusting with zinc oxid and starch, 
or zinc, bismuth, or diachylon ointments may be employed. In severe cases 
only the daily application of a 1 or 2 per cent, silver nitrate solution is effi- 
cacious. Bathing after each evacuation, as is advised by so many, I cannot 
sanction after my practical experience, and would rather warn against it. 
By its frequent repetition the distribution of the eczema is assisted. Much 
more advantageous is the omission of the bath and cleansing with oil. Nat- 
urally, with a simultaneous digestive disturbance and diarrhea the ordinary 
controlling measures must be employed. 



CONSTITUTIONAL DISEASES 

ICTERUS NEONATORUM 

To this point only the general affections of the new-born which owe 
their origin to some local cause have been considered, but there are also 
a number of constitutional changes which appear as such from the onset. 
Most interesting in this connection is icterus neonatorum. It occurs in 
about four-fifths of all infants and, according to Kehrer's compilation, in 
boys more frequently than girls, in children of primiparae more often than 
in those of multiparae, in breech presentations more commonly than in 
head presentations. After a prolonged or complicated labor the child is 
often decidedly jaundiced. Debilitated children, premature or asphyxiated 
new-born, are especially predisposed. Jaundice usually appears upon the 
second day after birth, more rarely upon the third or fourth day. The dis- 
coloration, peculiarly, first occurs in the skin; in contrast to stasis icterus 
of the adult the conjunctivas are only affected in the severer cases and later. 
According to Porak, in regard to the intensity of the jaundice three grades 
may be differentiated: In the first the yellow discoloration is limited to 
the skin of the face, the chest, and the back ; in the second the abdomen and 
upper portion of the extremities and the conjunctivae are affected; in the 
third even the hands and feet are involved. The duration of the jaundice 
as a rule depends upon its intensity. In the mildest stage, without involve- 
ment of the conjunctivas, it sometimes disappears in three or four days. In 
the severer grades it may continue until the second or the beginning of the 
third week. The feces are never decolorized. The urine in the milder 
forms is not altered but in the severer cases becomes distinctly or even deeply 
yellow. The biliary coloring matter is found in the urine principally as a 
color infiltration of cell masses and casts, less often in diffuse solution. Ac- 
cording to Cruse and Halberstamm this varying distribution is also notice- 
able in the course, in that the latter appears later and is the first to disappear. 
On account of the comparatively slight amount of coloring matter the Gme- 



CONSTITUTIONAL DISEASES 97 

lin reaction is obtained with great difficulty and because of the failure of re- 
action there has long been a doubt as to the identity with biliary coloring 
matter. It is most frequently brought about after filtration of a large 
quantity of urine by the microscopic examination of the residuum. After 
the appearance of the yellowish brown cell masses the reagent is permitted 
to penetrate slowly under the cover glass. Hofmeier was the first to practice 
this tedious method of observation in a large number of new-born. Macro- 
chemically chloroform extraction, perhaps with subsequent evaporation, is 
necessary (Cruse). 

With this simple sketch the characteristics of the clinico-pathologic pic- 
ture of ordinary infantile jaundice are exhausted. Other deviations are ab- 
sent. The condition of the pulse corresponds to the norm. Its frequency, 
inversely to the consequences of stasis icterus in the adult, shows no diminu- 
tion. The temperature also is uninfluenced. Finally, there is no noticeable 
disturbance in the subjective condition: The child nurses well, sleeps 
quietly, and cries no more than others. This general conduct caused many 
authors to regard jaundice of the new-born as normal, physiologic. On the 
other hand, the minute investigations of metabolism in the first days of life, 
such as have been conducted by Porak, Cruse, and especially by Hofmeier, 
have revealed that jaundiced infants are liable to poorer nutritive conditions 
and especially the more pronounced the jaundice. Although this result 
must essentially strengthen the opinion that the condition is pathologic it 
is of greater importance in etiologic investigation and furnishes for prophy- 
laxis and treatment the support which was formerly lacking. 

As icterus neonatorum is not directly dangerous to life and infants never 
perish from it alone, the autopsy reports are exceedingly scant. This accounts 
for the tenacity with which the view was long maintained that the yellow 
discoloration was limited to the skin and conjunctivas. However, careful 
investigation of infants who have perished suddenly as the result of accident 
has in the course of time proved that the internal organs undergo a more 
or less yellow discoloration. It is a peculiarity that the cartilage, brain, and 
spinal cord are frequently affected, while in the stasis icterus of adults these 
regions are not involved. Less apparent, even in the severer forms, at least 
macroscopically, is the change in the parenchymatous organs — the spleen, 
kidney, and liver. In the last-named organ Birch-Hirschfeld demonstrated 
microscopically also in the mild grades a plentiful presence of biliary coloring 
matter. The icteroid discoloration is particularly distinct in the intima of 
the vessels, the endocardium, the serous membranes, and in the fluids secreted 
in these cavities. The mucous membrane of the intestines and the permea- 
bility of the ductus choledochus and ductus hepaticus always remain normal 
in ordinary icterus neonatorum. In the kidneys, in addition to a generally 
more decided hyperemia, the chief characteristic is the constant finding of 
uric acid infarcts, with which occasionally there is an accumulation of pigment 
excretion. The latter, the much disputed bilirubin crystals, considered chemi- 
cally identical to hematoidin crystals, have been found by Orth and Neumann 
8 



98 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

also in other tissues and in the blood of icteroid infants who have perished. 
This observation was for a long time the main support for the theory of a 
hematogenous origin of biliary coloring matter and therefore of jaundice. 
Later investigations, however, have furnished positive proof that this only 
results from a special secondary change after death — a cadaveric condition. 
C. Ruge found these excretions also in the macerated fetus; Neumann, in 
children who died immediately after birth, therefore before jaundice could 
be developed. Finally, Hofmeier was never able to demonstrate such crystals in 
his numerous examinations of the blood of living icteroid infants nor by pro- 
longed preservation of his preparation could their formation be noted. 

In regard to the origin of icterus neonatorum there is still a great differ- 
ence of opinion. The view formerly held of a hematogenous relation must 
be rejected as untenable, at least in its' original sense that either the hemo- 
globin which is freed by the destruction of red blood corpuscles is changed 
immediately into biliary coloring matter in the circulation or that this alter- 
ation occurs in the small and large blood extravasations in the skin or in the 
internal organs even after a normal birth. After the investigations of Hayem, 
Violet, and especially of Hofmeier and Silbermann there can certainly be no 
doubt in regard to certain changes in the blood, in icterus neonatorum, espe- 
cially that the erythrocytes are destroyed and become free and that hemoglobin 
thus finds its way into the circulation. Physiologic researches of the last 
decade, however, have furnished undoubted evidence that even under such 
conditions the hepatic cells preside over the direct formation of biliary con- 
stituents in the secretion of bile, the function of which is not limited to a 
simple excretion of pre-formed products in the blood. If, therefore, the 
presence of biliary constituents in the fluids of the tissues and in the urine 
is to be regarded as a reliable sign of the hepatogenous origin of the existing 
jaundice, this is especially true of the bile acids, of which another point of 
formation than that of the hepatic cells is unknown. Birch-Hirschfeld-Hoff- 
meister and subsequently Halbertsamm succeeded in substantiating this argu- 
ment in the pericardial fluid. In the icteroid new-born this was found to con- 
tain bile acids ; in the non-icteroid it was free of bile acids. The latter result 
should answer Gesner's criticism that in these cases a diffusion of bile occurred 
post mortem. As the result of this investigation icterus neonatorum must 
be regarded as positively hepatogenous, due to resorption of the biliary con- 
stituents formed by the liver cells. The question then remains, to what may 
this absorption be due. It is obvious that a condition such as occurs in the 
jaundice of adults — a hindrance in the flow of bile — should first be considered. 
In this sense Yirchow has suggested the possibility of an accumulation of 
mucus and epithelium in the ductus choledochus. According to Epstein and 
Cruse the biliary passages, like other organs (for example, the mouth), in 
consequence of circulatory changes after birth, are subject to a hyperemic, 
catarrhal, irritative condition with desquamation of epithelium, which causes 
a constriction or closure of the lumen. Finally, Kehrer considered congenital 
narrowness of the excretory ducts. All of these attempted explanations are 



CONSTITUTIONAL DISEASES 99 

purely theoretic and lack anatomic foundation. It has already been stated 
that in ordinary icterus neonatorum the feces retain their color and that 
signs of obstruction of the flow of bile into the intestine are absent. The 
greater difficulty with which the bile is discharged by pressure upon the gall- 
bladder in the autopsies of the new-born in comparison to adults exists to 
the same extent in icteroid and in non-icteroid subjects. Those cases in 
which an actual closure of the excretory duct occurred during life are char- 
acterized not only b}^ a certain degree of yellow discoloration but also by a 
greater involvement of the general condition. If such complications occur 
at all they can play a part only in a very small minority of the cases. 

A second group of authors takes the wider view that biliary stasis is due to 
the circulatory changes to which the liver is subject after birth. It was 
thought that with the arrest of the placental circulation a stasis of blood 
developed in the vascular area of the hepatic and portal veins and caused 
pressure upon the biliary passages. This consideration, originating from 
West, Hewitt and Weber, which was at first only theoretic, was subsequently 
found, through the anatomico-pathologic investigations of Birch-Hirschfeld, 
to be based upon fact. The more or less extensive edema of the periportal 
connective tissue, demonstrated by this author in icterus neonatorum, was 
regarded as stasis edema, due to the stoppage of the umbilical vein circulation 
and an insufficient activity of respiration. Shortly afterward Cohnheim re- 
ported a series of observations in ordinary icterus neonatorum in which no 
edema of Glisson's capsule could be demonstrated. Hofmeier called atten- 
tion to the fact that in the autopsy findings of Birch-Hirschfeld there were 
only the extremes of circulatory and respiratory disturbances, from which the 
infants eventually perished. A generalization of these conditions to the effect 
that between the normal, vigorously breathing and the asphyxiated child the 
most manifold intermediate stages exist and that the consequences of deficient 
respiration become noticeable in proportion to the frequency of icterus neona- 
torum, therefore in about 80 per cent, of the cases, is absolutely untenable 
according to the experience of obstetric practice. Finally, Stadelmann utilizes 
in comparison the sequels in uncompensated valvular lesions of adults. The 
severest grades of liver stasis only give rise to a very slight icteroid discolor- 
ation, and even these cannot be referred to pressure upon the dilated vessels, 
but, on the contrary, to the interstitial connective tissue proliferation by which 
the biliary passages are only secondarily compressed. Accordingly an eventual 
cooperation of blood stasis or of edema of the periportal connective tissue, 
even in the isolated cases of deficient respiratory activity which Hofmeier 
himself includes, is not probable. The other foundation for the development 
of blood stasis in the liver (Silbermann) by a fermentemia resulting from 
destruction of blood corpuscles does not permit this compression theory as 
the cause of icterus neonatorum to be recognized and has already been rejected 
by Stadelmann. 

Another group of authors adheres to the causal influence of the circulatory 
change in the liver after birth, but characterize it as a decrease of blood pres- 



100 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

sure with a lessening of tension in the capillaries of the hepatic parenchyma, 
and thus attempts to prove a direct transmission of bile into the blood 
(Frerichs, Naunyn, Schultze). Opposed to this view is the observation that 
icterus neonatorum is decidedly increased when the child receives post partum 
as much of the placental blood as is possible, either by a delayed tying of 
the cord or by expression of the cord and of the uterus. The increase of the 
general amount of blood, associated therewith, causes an increase of the general 
blood pressure, from which the portal vein cannot be excluded. Furthermore, 
experimental physiology has not been able to determine a decrease of bile 
secretion even after decided lowering of the blood pressure. Among the local 
hypotheses that of Quincke must be mentioned. He invokes the well-known 
biliary circulation in explanation, which in the new-born, in consequence of 
the direct communication of the portal vein with the vena cava, is diverted 
by the ductus venosus Arantii. Likewise as in the adult bile from the intes- 
tine is absorbed into the blood of the portal vein, and all the more readily 
in the new-born as the meconium contains a profuse amount of biliary con- 
stituents. While in the adult the blood of the portal vein is carried only 
to the liver and is there freed from deleterious products, in the new-born a 
portion of the impure blood finds its way through the ductus venosus Arantii 
directly into the vena cava and thence into the general circulation. If the 
transference of bile into the fluids of the tissues in this manner causes the 
icteroid discoloration, the simultaneous presence of biliary acids in the blood 
must be responsible for the marked destruction of the erythrocytes. As con- 
vincing as this explanation appears at first sight, it leaves completely out of 
consideration the fact that jaundice does not occur regularly in the new-born 
and that when it is present its intensity varies considerably. Kehrer has 
emphasized that asphyxiated infants also, who have discharged their meconium 
largely intra partum, may become markedly jaundiced and that a coincidence 
of intensity with a slow or rapid evacuation of meconium cannot be demon- 
strated. To explain the exceptional cases by the assumption of a special 
stimulation of absorption on the part of a greater intestinal peristalsis means 
to base one Irypothesis upon another, which will probably satisfy no one. 

From this discussion it is obvious that none of the theories is sufficient 
for all requirements, and our lack of knowledge of the more profound circu- 
latory and secretory processes, that is, the changes in the liver of the new- 
born, and the hypotheses therefore required, make it doubtful whether this 
method of search for a local cause will meet with success. Accordingly the 
investigations which were recently begun are to be welcomed. These take 
into consideration the entire life — or pathologic picture of the icteroid new- 
born so as to determine the difference between their condition and that of the 
non-icteroid. Hofmeier was probably the first to enter upon this research 
and has furnished us valuable evidence. In the first days of life jaundiced 
infants are subject to a greater loss in weight, due entirely to the consump- 
tion of their own body albumin. The slower and later compensation proves 
that also in subsequent days jaundiced infants possess a slighter energy of 



CONSTITUTIONAL DISEASES 101 

growth. The excretion of urea which under normal circumstances shows 
a primary rise until the third day and a beginning decrease from the fourth, 
shows in the first nine days a demonstrable and decided increase. The forma- 
tion of uric acid shows the same relation: the signs of uric acid infarct and 
its accompanying phenomenon, albumin in the urine. Hand in hand with 
these anomalies in metabolism is the change in the blood which, according to 
the microscopic investigations of Hofmeier and Silbermann is characterized 
by a destruction of red blood corpuscles and an abundant formation of im- 
mature and more resistant forms, and in jaundiced children is even more de- 
cided. Hofmeier associates the disturbances of metabolism with the deficient 
nourishment of the child in the first days, either quantitatively (slight secre- 
tion of milk, primiparae) or qualitatively (artificial nutrition), or with its 
incomplete assimilation (premature birth). In consonance with the law of 
the physiology of metabolism in such conditions of inanition the albumin of 
the circulation is first consumed. The change in the composition of the blood 
plasma, thus brought about, exerts an unfavorable effect upon the blood cor- 
puscles and increases the consequences of any exertion to which they are 
subject with the onset of extrauterine substantive respiration. The erythro- 
cytes are destroyed even more quickly; the older forms which still exist are 
destroyed to a greater extent and are substituted by juvenile stronger ones. 
The hemoglobin which is thus freed in greater amounts is the cause of an 
increased production of biliary coloring matter in the liver. The excreted 
bile is richer in pigment and therefore thicker. The normal regulation be- 
tween formation and flow is therefore the more readily subject to disturbance 
as the beginning of intestinal digestion establishes a more rapid increase of 
bile. The consequence is relative insufficiency of the excretory ducts, which 
in turn leads to stasis and absorption, therefore to jaundice. Finally, there 
remains the further destruction of the cell stroma of the blood corpuscles 
which Hofmeier is inclined to associate with the increased production of uric 
acid and the greater development of the uric acid infarct. Although this 
theory in its component parts does not entirely remove certain objections, 
nevertheless the fundamental view that the peculiar conditions of metabolism 
of the first days of life are in causal connection with the development of 
icterus neonatorum has much in its favor. The other possibility that the 
anomalies of metabolism are the consequences of jaundice appears exceed- 
ingly unlikely, for the reason that, according to general opinion, the amount 
of absorbed bile is exceedingly slight and the flow of bile into the intestine, as 
already mentioned, suffers no direct obstruction. Against the assumption of 
an independent accompanying condition is the regularity and especially the 
uniformity of the differences in degree. In support of this view it must be ac- 
cepted that children who externally show no icteroid discoloration, neverthe- 
less have biliary coloring matter in the urine. The greater predisposition also 
of premature children and those born at term but less well developed becomes 
more readily comprehensible by a slighter activity or a disproportion between 
requirement and assimilation. The experience of practice agrees with this. 



102 DISEASES OF THE NEW-BORX IN THE FIRST DAYS OF LIFE 

Since I have ceased to permit the child to hunger until there is an adequate 
secretion of milk and have seen to it that the child at once receives sufficient 
food I have much less frequently met with well marked and severe forms of 
icterus. This difference becomes especially obvious when a wet-nurse is em- 
ployed from birth. 

Diagnosis. — The diagnosis of ordinary icterus neonatorum is easily made 
by inspection; its correctness is confirmed by the additional observation that 
the child apparently is otherwise normal and by the subsequent disappearance 
of the discoloration without treatment. In the differential diagnosis of the 
severer and more protracted forms all of those diseases must be considered 
which give rise to demonstrable jaundice in the new-born. In this connection, 
among the general diseases septic and pyemic infections have already been 
mentioned, and among the local diseases, syphilis of the liver, either diffuse, 
as hepatic cirrhosis, or circumscribed, as gummatous infiltration. To these 
must be added Buhl's and Winckel's diseases, which will be described more 
fully later, the sequels of gastro-intestinal catarrh, the so-called catarrhal 
jaundice, and anomalies of development in the biliary excretory ducts. In 
addition to the special symptoms it is important to note that children with 
these conditions, in contrast to icterus neonatorum, present a more or less 
serious pathologic appearance. Among the malformations we must consider 
congenital obliteration and complete absence of the larger bile passages. In 
these conditions the jaundice is especially marked, usually of a greenish- 
yellow hue. The feces are decolorized, clay-like, whitish. In addition there are 
the signs of gastro-intestinal catarrh. With increasing emaciation the chil- 
dren perish in a few weeks, exceptionally later. Such examples are quite 
scarce in the literature (Henoch, Giese, Gessner, etc.). 

Prognosis. — The prognosis of ordinary icterus neonatorum may generally 
be regarded as favorable. Nevertheless, in debilitated children the greater 
consumption of the body albumin and the resulting hyponutrition must be 
considered. The prognosis of symptomatic jaundice depends upon the causal 
affection, and therefore, as the condition is usually grave, it must be looked 
upon as unfavorable, on which account the term "malignant" is used by many 
authors for this variety. 

Treatment. — The prophylaxis of ordinary jaundice must be directed 
primarily toward the exclusion of all conditions which, according to experience, 
increase the intensity; therefore the complete relief of asphyxia, sufficient 
warmth, especially of feeble or premature children, and early regulation of the 
proper diet. These same points are also operative in the therapeutic treat- 
ment, of which increase in food and the prompt relief of the consumption of 
body albumin are primary. Special drug treatment, such as syrup of rhubarb, 
which was formerly customary, is absolutely unnecessary and is rather to 
be rejected in view of its tendency to still further decrease the absorption of 
food. 

The prophylaxis and treatment of symptomatic jaundice, in so far as this 
condition comes into consideration at all, depend upon the causal affection. 



CONSTITUTIONAL DISEASES 103 



PEMPHIGUS NEONATORUM 

We are much better informed regarding the pathologic importance of 
pemphigus neonatorum. In the simple variety vesicles appear suddenly, 
usually during the night, upon the skin of the trunk, sometimes isolated, at 
other times quite numerous, in irregular distribution from the size of a lentil 
to that of a pea, and surrounded by a red areola. A further distribution 
occurs in crops, similar to its first appearance. Simultaneously the vesicles 
already present increase in extent to the size of a hazelnut or a walnut, a 
pigeon's or even a hen's egg, the adjacent vesicles unite and a large complexus 
may be formed. The shape of the smaller prominences are semiglobular ; the 
larger ones are more oval. In addition the latter show a less degree of full- 
ness, probably in consequence of the more extensive evaporation of water upon 
the surface. They are no longer tense, but flaccid or even undulating. The 
contents eventually undergo a qualitative change; at first serous, gray, trans- 
parent, the vesicles and blisters become purulent, opaque, and yellow. The 
final course varies. In some of the vesicles, especially the smaller ones, desic- 
cation occurs : A crust forms which gradually loosens as the epithelium is re- 
placed. Others, particularly the larger ones, rupture and leave a slightly oozing 
surface over which the skin eventually forms. The affected areas are character- 
ized for some time by a more marked pigmentation, which finally disappears 
without cicatrization, leaving no trace of the former disease. 

As has been stated, the first eruption commonly occurs upon the trunk 
and most frequently upon the skin of the abdomen, in the vicinity of the 
navel or toward the inguinal region. In its further distribution the neck 
and head are involved. The extremities are usually not affected until the 
process upon the trunk is well developed. The palm of the hand and the sole 
of the foot are in the majority of cases exempt. Disease in these regions is 
exceptional. There are a few reports of a vesicle formation upon the mucous 
membrane of the mouth, especially of the lips, the hard palate, and the tongue. 

The extension of the cutaneous process varies greatly in different cases. 
All of the transitional stages from the appearance of a few isolated vesicles 
to a more or less dense covering of the larger portion of the surface of the 
body have been observed. 

Pathologico-anatomically the localization and the nature of the process 
correspond closely with ordinary inflammatory vesicle formation. Here 
also we are concerned with an accumulation of fluid, due to exudation and cell 
absorption, between the horny layer and the mucous layer of the epidermis, 
by which the former is raised. An inner partition is present only in the smaller 
ones ; the larger vesicles are of one chamber throughout. 

The disease begins usually in the second half of the first week, rarely earlier, 
exceptionally later. The period of progression seldom extends beyond the 
end of the second week and the process terminates on an average in three or 
four weeks. 

With moderate vesicle formation the general condition as a rule reveals 



104 DISEASEvS OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

no special change. The child eats, sleeps, etc., just as before. Distinct 
prodromes are absent. The temperature of the body remains normal or shows 
only a slight rise at the time of the eruption and of the relapses. Large and 
particularly confluent vesicle formation is more frequently associated with 
high, occasionally prolonged fever and corresponding constitutional symptoms. 
Eupture of the vesicles in various areas leads to more or less circumscribed 
epithelial defects which readily tend to suppuration, especially when the 
activity of skin formation is deficient. By repeated vesicle formation at the 
periphery the excoriations ma}^ constantly enlarge (pemphigus foliaceus). 
Under such circumstances the nutritive condition surfers. The infant becomes 
more and more debilitated and may succumb from gradual loss of strength 
or sudden collapse. These unfavorable cases associated with more or less 
severe symptoms are exceptional. Although from their course they justify 
the adjective "malignant," nevertheless, for a separation as a substantive form 
of disease there are no other points of support. 

Pemphigus Cacliccticus. — Under this term Caillault has described a spe- 
cial variety : in feeble, greatly debilitated children with extensive vesicle erup- 
tion upon the trunk, head, and extremities including the palmar and solar 
surfaces, high fever, marked alteration of the constitutional condition, and 
diarrhea. The entire course, in contrast to ordinary acute pemphigus neo- 
natorum, has a more chronic character and continues usually for several 
months. All of these peculiarities are referred to the cachectic condition. 
With the extensive clinical material of the Berlin Charite Henoch was unable 
to convince himself of the existence of such an affection except when asso- 
ciated with syphilis. In all cases of this kind which came under observation 
the autopsy showed definite specific lesions. Other authors coincide with 
Henoch so that Caillault's findings require further confirmation. 

The question now arises whether ordinary non-s}^philitic pemphigus 
neonatorum may also be congenital. Henoch, Wickham, Legg, and von 
Winckel have reported such observations. The peculiar localization of the 
vesicular formation, the eruption which continues for several years, as well 
as the absence of any statement regarding the eventual propagation of the 
virus to other individuals make the uniformity with the simple form of 
pemphigus neonatorum exceedingly questionable; therefore a view of this 
kind is forced, to say the least. 

In association with pemphigus neonatorum furunculosis, deep ulcerations, 
and phlegmons are often observed ; therefore affections of a septic nature which 
are probably to be explained by a secondary infection of the contents of 
the vesicles or of the epithelial defects. These sequels are of special import- 
ance since they may seriously alter a favorable course and cause a lethal 
termination. 

The causal origin of pemphigus neonatorum is still quite obscure. It is 
positive, however, that the affection occurs by transmission and is therefore 
of an infectious nature. This is obvious from the occurrence of epidemics 
in cities (Olshausen-Mekus), in lying-in institutions (Eigb}^, Hervieux, Ahl- 



CONSTITUTIONAL DISEASES 105 

feld, von Winckel, Faber, Almquist, and others), and finally from the cumula- 
tive cases in the clientele of certain midwives (Koch, Dohrn, Zechmeister, 
Bodenstab). The fact that with strict isolation the further distribution may 
be arrested is especially important (Moldenhauer, Dohrn). The transmission 
to nurslings occurs most frequently through a third person ; midwife or nurse. 
The tenacity with which the virus occasionally adheres to these persons with- 
out causing infection in them is conspicuous. Even after long suspension 
of their occupation, disinfection, a change of clothes, etc., the infection is 
renewed when again engaged in their occupation (Dohrn, Heubner). The 
direct transmission to persons in contact with the diseased child has also 
been occasionally reported; mother, wet-nurse, nurse, etc. The most familiar 
form is the eruption of pemphigus vesicles upon the mammary gland of the 
nursing mother or wet-nurse. In proportion to the number of infected new- 
born the disease is decidedly more rare in adults. Their slighter suscepti- 
bility is also evinced by a milder intensity of the symptoms which appear. 

How the transmission occurs, whether by contact, through the skin, or 
by way of the air passages, is not yet determined. Older authors incline to 
the latter, the recent ones to the former explanation. Convincing proofs of 
both methods apparently are present. Koch observed the first development 
of pemphigus vesicles on a child upon the genitalia and inner surface of the 
thigh, to which the nurse had to devote special attention on account 
of phimosis. A more striking example occurred in an adult who suffered from 
pemphigus of the face after using the towel that the suspected midwife had 
employed. On the other hand, Bodenstab reports the appearance of the disease 
in all persons with the exception of the physician who had entered the room 
of a diseased child. As proof of contact infection the results of inoculation 
in healthy persons of the contents of the vesicles is mentioned (Koch, Molden- 
hauer, Vidal, Blomberg). The vesicular eruption, however, only occurred 
in the immediate vicinity of the point of inoculation ; there was never a wider 
distribution. It is true these experiments were always made in adults who 
showed this limitation also with an accidental, natural transmission. But 
septic infection may lead to similar sequels. One or another of the pathogenic 
agents, as we shall see, is almost always present in the vesicular contents. 
Accordingly, with the simple inoculation of the contents of the vesicles the 
infectiousness is proven but not the method of transmission of pemphigus 
itself. 

The results of bacteriologic investigation of the vesicular contents vary 
just as greatly. The specific pyogenic organisms — in the milder forms the 
staphylococcus pyogenes albus and staphylococcus pyogenes aureus and in 
the severe cases the streptococcus pyogenes — which have been so frequently 
found, are to-day generally regarded as more or less accidental contaminations 
which complicate the affection in various ways and are of particular import- 
ance among the sequels. Of the others, from the many reports and particu- 
larly because of its frequent confirmation a diplococcus which has not yet 
been exactly classified, appears to be the most reliable and was first discovered 



106 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

and cultivated from the vesicular contents by Demme, and later by Claesen 
and Bulloch, and by Whigham from the blood of infants who had succumbed 
to pemphigus. By subcutaneous injection into mice and guinea-pigs, as well 
as by rubbing into their skins, this microorganism causes a general infection 
with a lethal outcome, the blood and organs bacteriologically showing the same 
coccus. A cutaneous eruption, however, was constantly absent so that the 
actual pathogenic agent is not proven even here. 

In addition to the view, based on the previously mentioned investiga- 
tions, that pemphigus neonatorum of itself represents a general infec- 
tion and is further complicated by the addition of septic microorganisms, 
another theory exists, especially among dermatologists, that there is at first 
a simple local affection of the skin and that a general disease is brought about 
only by secondary septic infection of the vesicles and excoriations. The favor- 
able course without any change in the constitutional condition in by far the 
greater majority of cases, the almost constant combination of severe general 
disease with local suppuration, render this view by no means unlikely. Riehl 
was able to demonstrate fungus elements which showed great similarity to 
trochophyton tonsurans, the generator of herpes tonsurans. The nature and 
the course of progression of this affection upon the skin it is true require con- 
sideration. A stepwise process as from a central point toward the periphery 
can only be recognized in the vesicular formation, never in the distribution 
of the cutaneous eruption upon the body. An irregular distribution of the 
germs by manipulations in the care of the child cannot be invoked in explana- 
tion for then the genitalia and their surroundings would have to show 
the first and most marked distribution. 

Lastly, Bohn and Dohrn have ascribed great etiologic importance to the 
effect of external cutaneous irritants of a mechanical, chemical, or thermic 
nature. In the first weeks of life, especially during the period of exfoliation, 
the skin of the child is said to possess a peculiar tendency to react to the 
formation of vesicles. Although this hypothesis as a general causal explana- 
tion has lost much in its original conception by the well-founded assumption 
of the infectious character of pemphigus neonatorum, the possibility can by 
no means be rejected that by damage and injury to the skin, no matter of 
what nature, the accumulation of the specific virus is facilitated ; therefore 
such cutaneous irritation, provided the germs are present, may be the active 
auxiliary factor. 

In the differential diagnosis the most important condition is pemphigus 
syphiliticus. Here the localization of the cutaneous eruption is an essential 
factor. Pemphigus syphiliticus in its first development shows a preference 
for both the palms of the hands and the soles of the feet, which in the simple 
form of pemphigus neonatorum are either exempt or are only involved after 
extensive distribution upon the trunk and extremities. In syphilis the chil- 
dren are commonly born with this cutaneous eruption ; in pemphigus this is 
exceedingly unusual. In addition to the vesicular eruption luetic children 
usually show other specific changes; macular or papular syphilid, condyloma, 



CONSTITUTIONAL DISEASES 107 

coryza. Furthermore, as a rule, in syphilis the infant is rapidly debilitated 
and succumbs in a few days. In regard to the composition of the local cuta- 
neous affection it must be mentioned that so long as the syphilitic pus- 
tule remains small it presents a flaccid fulness and after rupture leaves an 
oozing surface which of itself shows no tendency to heal. Finally, the positive 
result of the anamnesis of the parents and their clinical examination is de- 
cisive. 

Prognosis. — According to the description of the clinical course in the ma- 
jority of cases the prognosis is favorable, but with an extensive and in particu- 
lar a large vesicle formation, together with suppuration and an increased tem- 
perature, a complication with intestinal catarrh, and the subsequent appearance 
of furunculosis, ulceration, and phlegmons, the prognosis shows a correspond- 
ing change for the worse. 

Treatment. — In prophylaxis the prevention of transmission is the first 
requirement. Eeliable methods to protect the child itself from the disease, 
in other words to prevent the primary development, are unknown. Neverthe- 
less the proposition to treat every injury of the skin by hot baths, indifferent 
care of the child, etc., is not advisable even for ordinary sanitary reasons. It 
is most important to limit the focus of the affection once it has appeared. 
Strict isolation, not only of the diseased child but of all who come in contact 
with it, particularly other infants, is primarily essential. The same is true 
of all the utensils, clothing, bandages, etc., which should be thoroughly dis- 
infected or preferably destroj-ed by fire. In institutions the greatest danger 
of propagation is through the nurses; in general practice, by the midwife, 
and no less so by the physician. Before attending another case or confinement 
the most careful cleanliness and disinfection of the body as well as of all 
the clothing is absolutely necessary. Simple washing in water is quite insuffi- 
cient. The hair and the beard must also receive attention (Heubner). We 
must never omit to explain to the relatives the readiness of direct and indirect 
transmission and to insist upon caution. 

The treatment is expectant. Measures which will positively influence the 
course are unknown. It is advisable to protect the vesicles so far as possible 
from mechanical injury and facilitate their desiccation. This caution is par- 
ticularly necessary in handling the child. The cleansing should not be done 
by rubbing but by swabbing with cotton or gauze. The drying after the bath 
is best accomplished by enveloping the child in cotton. When the vesicles 
are small free dusting with zinc-starch, or zinc-talcum, equal parts. Larger 
eruptions in which rupture is unavoidable are most advantageously treated 
like burns of the skin: artificially emptied and covered with a bandage of 
salve or oil (zinc, boracic acid, bismuth, dermatol salve, oleum lini with aqua 
calcis). The same treatment is indicated when oozing areas have developed. 
Some physicians advise compresses with aluminum acetate ( 1 to 2 per cent. ) . 
Others are opposed to the daily bath, but on account of the more ready and 
careful cleansing by this means I believe it to be especially necessary. As 
adjuncts to the bath astringent substances (alum, tannin, oak bark), par- 



108 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

ticularly in severe cases, arc very advantageous. To prevent a secondary 
septic infection (furunculosis, ulceration, phlegmons) antiseptic baths con- 
taining potassium permanganate are given daily, or, in addition to the 
astringent bath, corrosive sublimate (0.3 to 0.5 per bath). 

Besides this local treatment the constitutional condition requires con- 
sideration; therefore, the best nourishment — from the mother or wet- 
nurse — and, with threatening collapse, analeptics: wine, brandy with water, 
etc. 

In syphilitic pemphigus the prompt institution of specific treatment is 
indicated but is rarely capable of preventing the further decline of the usually 
miserable subject. 

DERMATITIS EXFOLIATIVA 

This rare form of disease shows great similarity to the resulting conditions 
of pemphigus and was described by Hitter toward the end of the seventh 
decade of the last century. Behrend attempted to prove that this was only 
a variety of the condition known as pemphigus foliaceus. This view, how- 
ever, could not be maintained. On the contrary, we now generally regard 
dermatitis exfoliativa as different from pemphigus and as a substantive dis- 
ease. The principal characteristic is the ready exfoliation of the skin. 
Similar to the condition in the macerated fetus, large areas may be raised 
from their substrata or rubbed off, as occurs so readily in a more or less 
distributed extent in the ordinary care of the infant. Pathologico-anatomi- 
cally there are reports of an exudation into the lower epithelial layer, the rete 
Malpighi, therefore between the papillary body and the horny layer. In con- 
trast to pemphigus the amount of the exudate is so slight that as a rule 
vesicular formation does not occur or is only suggested in isolated areas. The 
second difference is the local distribution of this change: It does not appear 
in disseminated foci, as in pemphigus, but begins in one area, usually on the 
head, and in a short time extends diffusely over the whole or the larger 
portion of the body. 

As a rule the affection begins in the first or second week of life. Other 
sjmiptoms of characteristic nature, such as fever, etc., are absent. Recovery 
occurs by gradual regeneration of the epidermis and under favorable circum- 
stances is complete in a few weeks. In debilitated or premature children 
the prognosis is unfavorable, but even then the cause of death is usually due 
to some complication (pneumonia, digestive disturbance). 

The cause of the disease is still obscure. Worthy of note is its predomi- 
nantly epidemic nature. Bitter was of the opinion that it was the consequence 
of a septic general infection. Certainly, the decreased frequency upon im- 
provement of the hygienic conditions in the Prague Foundling Asylum was 
very conspicuous. 

The treatment is the same as for pemphigus; astringent baths, applica- 
tions of powder, and above all good nourishment — whenever possible from 
the breast. 



CONSTITUTIONAL DISEASES 109 

SCLEREMA NEONATORUM 

Much more rare, even in lying-in institutions and foundling asylums, is 
sclerema neonatorum. The name arises from a peculiar hardening of the 
subcutaneous cellular tissue with moderate swelling. In a more or less cir- 
cumscribed area, usually first upon the legs (calf, dorsum of the foot, thigh), 
but occasionally upon the cheek, the skin becomes hard, tense, as if infiltrated, 
and can no longer be forced into folds. Upon pressure by the finger no 
depression remains. The swelling has a soft, bacon-like consistence and at 
the same time is cool to the touch. The skin appears dry and pale, some- 
times of a grayish yellow or gray-blue color, according as to whether or 
not jaundice is present. This change gradually extends, is distributed to 
the lower extremity or to the face, and slowly proceeds along the back and 
to the arms. The anterior surface of the neck and of the chest, the penis, 
scrotum, vola manus and planta pedis, are usually uninvolved. With this 
extension active and passive limitation of movement is associated. The ex- 
tremities become stiff, cadaveric, and this is also true of the countenance. 
With an involvement of the lips ingestion of food is difficult or impossible. 
Finally, the infant lies with limbs extended as if made of wood or stone, 
immovable, and remains so when lifted. The feeble movements of the 
thorax and occasionally of the lips are the only signs of life. The process 
does not reach such general distribution in every case. If death occurs early 
the change may be limited to the legs or to the face alone. 

With this change in the body surface a more or less severe alteration of 
the constitutional condition occurs. The temperature of the body becomes 
more and more subnormal. Temperatures of from 34° to 30° C. (93.2° 
to 80° F.) or as low as 28.5° and 22° C. (83.3° and 71.6° F.) have been 
reported. The rapidity of the pulse decreases to 80 or even 60 per minute. 
The quality becomes weaker and softer. This coincides with the results of 
palpation and auscultation of the cardiac contraction, which at last is 
scarcely perceptible. The respiration usually is slowed, irregular and super- 
ficial, but sometimes, in consequence of a complicating pneumonia, it is rapid. 
Briefly, there is a constantly increasing general debility to which the infant 
succumbs within one or two weeks, rarely later. 

Pathologico-anatomically this cutaneous change is characterized first by 
a drying and rigidity of the subcutaneous fatty tissue. Upon incision no 
serous fluid appears nor can it be produced by stroking or pressure. The 
change has probably a more profound cause in the peculiar composition of 
the fatty tissue of the new-born, which according to Langer and Knopfel- 
macher contains more palmitic and stearic acids and less oleic acid; there- 
fore it may be a direct consequence of the decrease in the body temperature. 
In consonance with this is the fact that the sclerematous hardening gradually 
decreases under artificial warming in the incubator. In cases of more pro- 
tracted course, in addition to the decrease of fatty tissue an atrophic condi- 
tion of the connective tissue and epithelial constituents of the skin has been 



110 DISEASES OF THE NEW-BOllN IN THE FIRST DAYS OF LIFE 

reported. The only organic lesions found were a more or less extensive 
atelectasis of the lungs with fetal myocarditis, and in older children there 
was most frequently a gastro-enteritis or pneumonia, rarely nephritis. 

The etiology of sclerema neonatorum is obscure. We only know that 
debilitated, premature, or asphyxiated new-born who are poorly nourished 
and cared for, are predisposed to the disease; furthermore that the lessened 
activity of the heart plays an important role. From the frequent compli- 
cation with gastro-enteritis, so-called cholera infantum, it is proper to con- 
sider the results of an immoderate excretion of fluid and therefore an inspis- 
sation of the blood as the cause. In regard to pneumonia this explanation 
is less adequate. Here, as in the other cases, aid is invoked through the 
assumption of a congenital or acquired cardiac asthenia. There are reports 
of bacteriologic findings (Schmidt, Aufrecht) which, however, permit of no 
positive conclusions. 

From what has been stated the prognosis must necessarily be very un- 
favorable, especially when the child has been weak from birth. Nevertheless, 
Soltmann reports recovery in cases in which the disturbance of the general 
condition had not reached a very great extent and in which the scleremic 
cutaneous change was but partially developed. 

For the diagnosis the following is decisive: 1. Characteristic change of 
the skin — a firm, soft swelling without the ability to raise folds and without 
pitting upon pressure. 2. The fall in the body temperature. Differentio- 
diagnostically ■, the rigidity of trismus and tetanus differs in that the skin 
can be pressed into folds and the introduction of the finger into the mouth 
at once causes muscular contraction. 

The objects of prophylaxis are apparent: careful relief of the asphyxia 
and its consequences ; maintaining the warmth of feeble and premature chil- 
dren according to the methods already explained, and strengthening by careful 
regulation of food. 

In the treatment similar objects are necessary, and, in addition, energetic 
measures for the dangerous increase of debility and of the cardiac asthenia. 
The child is not only to be protected against decided loss of body heat but 
is to be kept thoroughly warm. The external temperature in the incubator, 
etc., must therefore be higher than is usual — about 44° C. (110.7° F.). A 
second essential requirement is feeding with breast-milk, either directly from 
the breast, or, if the infant cannot suckle, by means of a spoon er stomach 
tube. The administration of Tokay wine (10 to 20 drops every hour) or 
brandy (3 to 5 drops in water) is serviceable. Soltmann praises the in- 
fluence of massage and passive movements of the rigid limbs. In addition 
to stimulation of the local circulation the respiration and with this the cardiac 
activity are to be encouraged by the crying of the child. Finally, with respi- 
ratory difficulties, hot baths and ablutions (44 to 50° C.) are advised but the 
subsequent cooling brings with it disadvantages. 



CONSTITUTIONAL DISEASES 111 

EDEMATOUS INFILTRATION 

In addition to this actual hardening of the skin by rigidity of the sub- 
cutaneous fatty tissue an edematous swelling, due to serous infiltration of the 
subcutaneous cellular tissue, occurs in the new-born, with the same general 
constitutional symptoms. Both conditions are often designated varieties 
of sclerema — sclerema adiposum and sclerema oedematosum. Although 
there is a certain conformity of the general symptoms which suggests a cer- 
tain relationship, against this designation is the custom in the pathology of 
adults of indicating such transudations by the simple word " edema." 
Henoch describes both conditions under the one chapter heading of Sclerema 
Neonatorum, but he designates as sclerema merely the actual hardening, as 
edema the serous infiltration. In the latest text-book of Heubner there is 
absolutely no mention of sclerema oedematosum except as it is separated dif- 
ferentio-diagnostically from edema. AYith a knowledge of the clinical diff- 
erence this simplification of the nomenclature appears to me to be well con- 
sidered, as confusion is prevented by the sharp distinction of edema and 
sclerema. 

The edematous swelling is the same as in adults: The skin presents a 
uniformly tense, moist, glistening appearance. The color is waxy yellow or 
somewhat bluish, often slightly marbled. It is cool to the touch and leaves 
distinct depressions after pressure with the finger. This change usually 
develops in the calf and distributes itself to the foot, thigh and the genitalia. 
The trunk, the upper extremities, and the face are rarely affected. Occa- 
sionally the edema is limited to the lower portion of the extremities. The 
swelling is at first doughy, as in adults, and as it progresses it gradually 
becomes harder until eventually the finger leaves no depression. This con- 
dition, in contrast to the scleremic hardening occurs only when the swelling 
has reached a very high grade, while in sclerema it is observed from the 
onset. The same is also true of the limitation in movement due to the swell- 
ing and tension of the skin. 

The general disturbances are the same as those which have already been 
mentioned in detail in regard to sclerema: low temperature, decrease of car- 
diac activity, superficial, slow or irregular respiration; briefly, the picture of 
increasing general weakness. 

Pathologico-anatomically this cutaneous change is distinctly character- 
ized as a transudative infiltration, as edema. From the cut surface the se- 
rous fluid flows profusely. From the subcutaneous cellular tissue this 
transudation extends more or less to the intermuscular connective tissue. 
The autopsy findings only in exceptional cases reveal changes in the organs, 
which according to the experience of later life may be the cause. Demme 
reports fatal myocarditis, Elsasser and Henoch cases of nephritis. Under 
such conditions corresponding exudations are found in the peritoneum, 
pleura and pericardium. With the exception of gastro-enteritis, however, 
the primary cause of these diseases, and especially of nephritis, is obscure. 



112 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

More comprehensible is the pathologic development in congenital endocar- 
ditis and disease of the heart — observations which are actual curiosities. 
In the majority of cases the autopsy shows nothing characteristic. The sub- 
jects were usually premature, debilitated infants who merely presented the 
sequels of insufficient respiration (some degree of pulmonary atelectasis, 
ecchymoses, hyperemia of the liver, perhaps also effusion into the abdominal 
cavity) or of cachexia from some other cause (erysipelas, gastro-enteritis, 
etc.) or of poor nursing or improper nutrition. Here only a congenital or 
acquired cardiac asthenia can be considered responsible. The seeming in- 
completeness of this explanation has caused various authors to invoke other 
factors. Soltmann regards the salient points as a pathologic permeability 
of the vascular walls and an abnormal composition of the blood. Baginsky 
is inclined to regard infection as the cause. Naturally, not much is gained 
from these views. Notwithstanding all of these considerations the profound 
cause of this edema which thus far is regarded as idiopathic is entirely be- 
yond our knowledge. 

The prognosis, based on the severe and constant alteration of the general 
condition, is at least unfavorable. Most children succumb in a few days, es- 
pecially when complications such as gastro-enteritis and pneumonia exist. 
Rarely is the advance so moderate as to postpone the lethal outcome for two 
or three weeks. A few cases of gradual improvement have been reported. 

The diagnosis is based primarily upon the positive demonstration of 
cutaneous edema with decided constitutional disturbance. The variation 
from the scleremic change of the skin has already been mentioned. With 
e^sipelas there is more or less decided elevation of temperature in addition 
to a marked redness of the diseased cutaneous area. As the result of this 
affection, particularly in debilitated infants and when there has been poor 
nourishment and care, the above form of malignant edema may appear 
either as a complication or sequel. To be strictly differentiated from it is 
that form of cutaneous thickening, similar to the condition in adults, which 
occurs in the new-born after erysipelas in consequence of lymph stasis. 
Apart from the slower development and the milder course the great pros- 
tration and its gradual increase is conspicuously absent. 

In prophylaxis and treatment the same rules are to be observed as have 
been mentioned in the description of sclerema. 

Finally, it must be stated that both changes, sclerema and edema, may 
appear in the same child. Parrot, to whom we owe most of our knowledge 
of both clinical pictures, has described such cases. On account of the con- 
stitutional condition, which is the fundamental cause, the coincidence of these 
affections is not remarkable. 

MELiENA NEONATORUM 

It still remains to consider a number of pathologic conditions which pos- 
sess a special tendency to hemorrhage and hemorrhagic excretions. The 



CONSTITUTIONAL DISEASES 113 

most familiar of these, melaena neonatorum, is characterized by hemor- 
rhages in the gastro-intestinal tract, i. e., by the vomiting of such masses 
and their passage per anum. Both processes of discharge in varying fre- 
quency and quantity may be combined. As a rule the passage of blood by 
the bowel preponderates. A quantitative limitation also occurs but then 
principally affects the intestinal passages. The vomited masses frequently 
consist of more or less altered fluid or coagulated blood; the fecal discharges 
are usually of a dark, tarry appearance. The latter, in comparison to me- 
conium, are of a more thin, fluid consistence, in consequence of which they 
are more quickly and thoroughly absorbed by the bed pad. It is true, in 
early disease this difference may be more or less concealed on account of the 
admixture of meconium. 

Occasionally these hemorrhages occur a few hours after birth, but are 
most frequent upon the second day. Their appearance after the seventh day is 
rare. As extreme periods Genrich mentioned the eighteenth and Kundrath 
the twentieth day post partum. 

The disease usually arises suddenly without special prodromes. The 
evacuations occur at varying intervals and are more or less profuse. The blood 
loss soon reaches a serious amount: The infant becomes feeble, apathetic: 
the skin is pale, cool, the pulse accelerated, small, scarcely perceptible, the 
respirations rapid, superficial. Death sometimes follows with the signs of 
a hemorrhage after twelve to twenty-four hours. In particularly severe 
cases the signs of a large internal loss of blood are evident after the first dis- 
charge. In some of the cases the hemorrhagic exudation gradually ceases 
in the course of a day. First, the vomiting stops. The stools show a hemor- 
rhagic consistence for some time and only gradually assume a normal ap- 
pearance. The infant recovers completely provided that after an interval 
the hemorrhages do not begin anew, in which case death is almost inevitable. 

The mortality varies in different statistical compilations between 35 and 
60 per cent., therefore some authors regard a favorable outcome as common, 
others as rare. 

With these bloody evacuations and their sequels — increasing anemia and 
progressive loss of strength — the constant symptoms of the disease are ex- 
hausted. Further investigation is usually without result. The temperature 
is normal, or, if there is profuse loss of blood, subnormal. Marked tension, 
distension and sensitiveness in the gastric region or of the abdomen are rare. 
To suppose the presence of deep ulcerative processes in the gastro-intestinal 
canal appears to be justified according to some of the autopsy reports (Binz, 
Rembold), but according to others this is not so. 

In addition to this clinically apparent substantive form of melena there 
is another which occurs secondarily in certain general affections. In this 
connection the predisposition to septic infection and syphilis has already 
been mentioned. Buhl's disease which is regarded to-day as a modification 
of general sepsis, must also be mentioned. In these cases the hemorrhagic 
discharges usually begin somewhat later. The remaining symptom-complex 
9 



114 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

is correspondingly prolonged owing to the symptoms of the underlying af- 
fection. Thus, in the case of sepsis hemorrhages occur in and from other 
regions, for example, the navel, skin, mucous membranes, etc. Prolonged 
and intense jaundice with or without cyanosis, together with dropsy, make 
the likelihood of a general cause obvious. In syphilis the presence of spe- 
cific changes is conclusive. But lues hemorrhagica is now regarded as a com- 
bination of syphilis and sepsis. To this category also belong the acute exan- 
themata in so far as they affect the new-born, therefore particularly variola. 
Some authors connect melena with hemophilia, but their evidence is not con- 
vincing. Certainly the examples of heredity which have been reported (Kil- 
liet and Barthez) can by no means be regarded as unassailable. 

Melena belongs to the rarer affections of the new-born. It is impossible 
to estimate its frequency on account of the great variations in the statistical 
compilations. The extremes are 1:500 (Hecker, Buhl) and 1:2500-2800 
( Spiegelberg, O. Veit). Probably the average is 1:1500, which corresponds 
most nearly to the experiences of practitioners in general. 

Pathologico-anatomically melaena neonatorum, like similar conditions in 
the adult, cannot be regarded as a substantive disease but merely as a symp- 
tom of various pathologic processes and changes. In the constitutional dis- 
eases it is a part phenomenon of the hemorrhagic diathesis which is present 
also in the various organs. The same position is maintained in regard to the 
local diseases, except that the course of events and the active underlying 
cause are less obvious. According to the autopsy reports the etiologic sig- 
nificance is most positive in two processes: circulatory obstruction in the cor- 
responding vascular region, and superficial ulceration. The former, on ac- 
count of the thorough transformation which the fetal circulation undergoes 
after birth, is the more comprehensible. Other especially noticeable disturb- 
ances relate to the abdominal vascular supply and have already been detailed 
in the description of asphyxia. A direct influence, however, can be ascribed 
to asphyxia only under certain conditions, as asphyxia is compartively com- 
mon, melena very rare. Furthermore, children who suffer from melena are 
seldom asphyxiated when born (Kling, Silbermann). The view that only 
the severer grades of asphyxia are the cause of melena cannot be proven. The 
conditions are similar after abnormal and artificially terminated labors, 
which deserve note from the standpoint of a possible asphyxia. Therefore 
other auxiliary factors must exist which increase the influence of asphyxia 
or which are substantively capable of bringing about a similar effect. Among 
these in particular are injuries to the infant skull. In addition to obstet- 
rical conditions a marked venous hyperemia of the gastro-intestinal canal 
has been demonstrated at the autopsy' in consequence of accidents or crime 
(Kundrath). Pomorski regards lesions of the vasomotor center as the prin- 
cipal cause, for example, in intracranial extravasations of blood. This con- 
dition is said to give rise to hyperemia and hemorrhage in the lungs, in the 
stomach, and the duodenum, and to ulceration in the last-named area by cor- 
rosion on the part of the digestive fluid. He succeeded in strengthening his 



CONSTITUTIONAL DISEASES 115 

opinion by animal experiment, but further confirmation is not at hand. Of 
other traumata occurring at birth unskillful and rough handling of the in- 
fantile body in breech presentations might be serious so far as hyperemia 
causing hemorrhage from the mucous membrane and submucous hematomata 
or their rupture are concerned. To a certain extent also those organic 
changes must be considered which are regarded as responsible for similar con- 
ditions in adults. Meberding reports embryonic defects of the heart and 
of the large vessels but his conclusions have not been generally accepted. 
Hepatic diseases in the new-born, as already mentioned, arise principally 
upon a syphilitic basis, and assume the form of diffuse or miliary interstitial 
hepatitis. Usually these infants perish soon after birth from other symp- 
toms but the autopsy findings reveal a well-defined hyperemia of the mucous 
membrane of the gastro-intestinal tract, occasionally also hemorrhages and 
thromboses in the roots of the portal vein (Kundrath). Similar observa- 
tions have been made with regard to solitary gummatous focal disease when 
of great extent and in the immediate vicinity of the larger branches of the 
portal vein. In this connection the localization in the posterior portion of 
the lobus quadratus and in the anterior portion of the lobus Spigelli is es- 
pecially serious. Therefore, signs of circulatory obstruction are present. 
Early death prevents the development of further sequels. The possibility 
of an influence upon the further life cannot be excluded. Without special 
change in the liver the left branch of the portal vein might be endangered 
by a decided coagulation of blood in the adjacent portion of the umbilical 
vein, since this coagulation may eventually continue into the portal vein. A 
large obstructive thrombus in the upper portion of the umbilical vein adjoin- 
ing the liver is not rare and is due to insufficient derivation of blood, but in 
the early compensation of this irregularity it usually soon reaches the re- 
quired limitation. Only after long duration or extensive development of 
the circulatory disturbance is there an opportunity for further growth, there- 
fore for the consequences which we briefly ascribe to asphyxia. 

The question must still be considered whether in the new-born embolism 
of the gastric and intestinal arteries may occur. The occlusion of small 
branches often plays an important role in the pathogenesis of ulcerations 
which are peculiar to certain cases of melena (Landau). If this possibility 
is confirmed the occlusion of larger arterial branches must be considered. 
Landau regarded as the points of preference the umbilical vein and the ductus 
Botalli. According to our pathologico-anatomical views the first must be 
regarded as exceedingly doubtful if not impossible. At at events the source 
must be beyond the lungs. This prerequisite is alone fulfilled by the ductus 
Botalli. Its strength even in a less congested condition would aid the pro- 
pagation of a larger blood coagulum, therefore the occlusion of one of the 
larger branches. Its occlusion by thrombus formation is to-day regarded as 
pathologic; nevertheless, if the cases of puriform composition of the throm- 
bus are excluded, Eauchfuss noted it in about 0.7 per cent, of his investiga- 
tions. But in diseases of the heart the emboli distribute themselves within 



116 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

the region beyond the point of the ductus Botalli, so that the extremities are 
frequently, the spleen and kidney more rarely, and the mesenteric artery only 
exceptionally involved. Even if a blood coagulum reaches the celiac artery 
it is not ordinarily forced into the special vessels of the stomach and of the 
duodenum. The same relations hold for the ductus Botalli. The lesser 
distance is without importance and at most excludes the conduction to the 
head and to the upper extremities. Although by assuming a thrombotic 
closure of the ductus Botalli it is impossible theoretically to exclude the pos- 
sibility of embolism, such an occurrence in practice must be regarded as ex- 
ceedingly rare. 

Thus far we have only considered the causes of pure stasis of blood, 
therefore essentially those cases in which special superficial changes in the 
gastro-intestinal canal are absent. Upon removal of the hemorrhagic intes- 
tinal contents post mortem the mucous membrane appears more or less 
strongly injected, or after prolonged loss of blood it may be pale and anemic 
and all the other organs have a decidedly anemic appearance. Here we must 
accept the view of hemorrhage per diapedesis (oozing). 

Among the superficial changes in another series of cases intramucous or 
submucous extravasations of blood, erosions and ulcerations, particularly in 
the stomach and duodenum, have been found. The ulcerations possess all 
of the properties of the round ulcer of adults: oval or round and sharply 
limited as if made with a punch, with a funnel-shaped base, sometimes super- 
ficial, at other times reaching to the serosa or even perforating this structure. 
The size varies usually between that of a millet seed and a lentil ; but a diam- 
eter of 1 to 2 mm. has been reported (Winckel). Usually only a few are 
present ; a multiple development is rare. In the latter case the mucous mem- 
brane between is either entirely normal or more or less permeated with blood. 
Localization within the stomach appears to be somewhat more common than 
in the duodenum (Anders). Henoch observed an annular ulceration in the 
lower portion of the esophagus. In the further course, as in the peptic ulcer 
of adults, there is a possibility of perforation. 

The great similarity of the ulcerations in melena with those of the round 
ulcer of later life leads us to believe that here is the main source of the hemor- 
rhage. In the last decades this idea has gained ground, as in a large number 
of cases of melena this condition was a positive finding. On the other hand 
there are reports even of multiple ulcerations in the gastro-intestinal canal 
without melena or any evidence of hemorrhage in the intestinal contents. 
It is true such exceptions may be due to the failure of the arterial vessel to 
rupture. Nevertheless, we must conclude that ulcerations may be the cause 
of melena, although not necessarily so. 

Concerning the development of these ulcerations we have as little knowl- 
edge as of round ulcer in the adult. We are dependent more or less upon 
assumptions, the proof of which is still lacking and exceedingly difficult to 
establish. Most comprehensible is the nature of the development: that it is 
due to blood stasis, perhaps under the influence of a fatty degeneration of the 



CONSTITUTIONAL DISEASES 117 

vascular walls which at first causes extravasations of blood. The mucous 
membrane in the corresponding area thereupon loses its vital resistance to 
the digestive power of the gastric juice, necrobiosis occurs and thus it is de- 
stroyed (Kundrath). After breaking through the protective epithelial 
cover the further progression is assisted by destruction of the tissue. The 
development of ulceration in connection with smaller emboli (Landau) is 
subject in general to the same principle, but is less likely, as already men- 
tioned, if a lesion exists from which it might originate. The observations 
regarding apparent pyemia in which other diseases of a corresponding focal 
nature are also present are at most exceptional. 

That these ulcerations may develop in extrauterine life, therefore that 
their onset and distribution occur at the earliest intra partum, coincides 
with the current view of most authors. Spiegelberg, Bohn and others are of 
the opinion that with an early disease this period of time is too short for 
circumscribed ulcerations and that the onset of ulceration is to be antedated 
to the intrauterine period. Their etiologic attempts at explanation are 
more or less hypothetical and lack anatomic foundation. Nor is it apparent 
why even great defects may not arise soon after birth if we remember that 
the principal instigator, hemorrhagic infiltration, may have already occurred 
intra partum and that the corrosive effect of the gastric juice requires but 
little time. 

Diagnosis. — The diagnosis of melena is naturally based first of all upon 
the knowledge that the evacuated hemorrhagic masses actually originate 
from the gastro-intestinal canal. In hemorrhages from the nose, mouth, and 
pharynx, and even from sucking at the wounded nipple of the mother, hema- 
temesis and entorrhagia have been observed. A careful observation of these 
changes is therefore always in place. However, such conditions, designated 
by the term " melaena spuria," are rare in the first days of life and are not 
nearly so liable to cause as rapid and severe conditions of debility. 

Prognosis. — The prognosis is uncertain. The outcome in the individual 
case naturally depends upon the strength of the child and particularly upon 
the amount and duration of the blood loss. If, after forty-eight hours, the 
excretions show no sign of abatement, the prognosis is correspondingly more 
grave. According to Silbermann no child in whom hemorrhage has lasted 
longer than seven days has lived. The prognosis is most unfavorable when 
the condition is due to pyemia or septic infection. After the arrest of the 
hemorrhage there is a possibility of serious sequels. Sometimes the infants 
recover very slowly and for a long time or even permanently are retarded in 
their physical development. Some authors report a diminished resistance 
of the digestive tract and a ready tendency to dyspepsia and diarrhea. 

Treatment. — Prophylactically the principal attention must be directed to 
the prevention of septic infection; notably, careful treatment of the umbili- 
cal wound according to the principles which have been explicitly detailed. 
Whether Landau's propositions for tying the cord are actually of much value 
is doubtful. In the absence of an urgent reason the cord is to be tied only 



118 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

after it has ceased to pulsate, or, more correctly, when it collapses, and the 
ligature is first to be applied close to the body and afterward above. 

In treatment, combating the hemorrhage and strengthening the general 
condition are of most importance. The primary requirement is rest, i. e., 
the infant should be kept in its crib and moved as little as is necessary for 
its care. The application of cold to the abdomen, especially of an ice bag, 
advised by many authors, readily aids collapse. Warmth (enveloping in 
flannel), and the addition of heat (hot water bags, incubator) are of essen- 
tial influence in the local disease in raising the general condition. The 
most suitable food, naturally, is breast-milk. When there is much vomiting 
the frequent administration of cooled milk with a teaspoon is effective. 
The employment of enemata (ice water, styptic solutions) is not advisable 
on account of their stimulating peristalsis, especially as the point of bleed- 
ing cannot be reached. Among the remedies formerly much employed were 
liquor ferri sesqui chloridi (one drop every hour in gruel), and ergotin by 
the mouth or subcutaneously (0.02-0.05 per dose). Recently, by the advice 
of Carnot, gelatin solutions have been employed for the arrest of hemor- 
rhage (Zuppinger). These are to be given in a 5 to 10 per cent, solution 
subcutaneously or by the mouth. When employed subcutaneously it is nec- 
essary to see that the solution has been recently sterilized. 

Threatening collapse calls for the ordinary measures indicated in severe 
blood loss: low position of the head, envelopment of the extremities, analep- 
tics (wine, brandy, ether). 

After the arrest of the hemorrhage good food (mother's milk) and 
warmth are necessary. 

BUHL'S DISEASE 

Another affection in the course of which there is a special tendency to 
hemorrhage is acute fatty degeneration of the new-born, or as it has been 
called for its discoverer, BuhPs disease. The first designation is based upon 
the pathologico-anatomical demonstration of extensive parenchymatous in- 
flammation terminating in fatty degeneration of the heart, of the kidney, 
of the liver, and even of the transversely striped muscles. 1 In this relation 
the affection shows great similarity to the sequels of poisoning with phos- 
phorus and arsenic. The changes in the organs are sometimes quite similar, 
at other times varied, some of them already showing advanced fatty degen- 
eration, while others are yet in the stage of parenchymatous inflammation 
or may even appear normal. The spleen is usually enlarged, softened, occa- 
sionally somewhat flabby. The hemorrhages occur as ecchymoses or as large 
extravasations in the skin, the mucous membranes, the meninges, the pleura, 

1 Even tendons and ligaments. Fifty years ago Dr. Geo. T. Elliott exhibited before 
the N. Y. Pathological Society many parts of a full-grown baby delivered under pe- 
culiar circumstances. It was a breech presentation. Gentle pulling on the feet tore 
them off. The same occurred as the result of traction on the rest of the lower ex- 
tremities. The severing of the parts took place in the joints. — Editor. 



CONSTITUTIONAL DISEASES 119 

the pericardium, the mediastinal connective tissue, the thymus gland, the 
peritoneum and the muscles. In the lungs the hemorrhage occasionally as- 
sumes the form of a hemorrhagic infarct. The bronchi contain hemorrhagic 
mucus or pure blood; the alveolar epithelium shows fatty degeneration. The 
mucous membrane of the gastro-intestinal canal is permeated with ecchy- 
moses and extravasations of blood, its contents are more or less tinged with 
blood, at other times of the nature that is so characteristic of melena. 

The clinical picture shows few characteristic phenomena, general symp- 
toms being the rule. Some of the infants are born at full term and appar- 
ently normal, others are asphyxiated when born without any demonstrable 
cause. The respiration is superficial and irregular and reacts to stimulation 
only transitorily or not at all. The face remains pale and slightly cyanosed. 
The infant is apathetic, nurses badly, and whimpers rather than cries. Other 
infants at birth present an entirely normal condition, the debility appearing 
after a few days. The icteroid discoloration of the skin soon becomes intense 
and simultaneously cyanosis of the face is more conspicuous. In connection 
therewith are extravasations of blood and ecchymoses in the skin, the con- 
junctivae, and the mucous membrane of the mouth. When the umbilical cord 
separates there is slight or marked parenclrymatous hemorrhage. In addition 
there ma^ be hemorrhage from the nose, the mouth, hematemesis, and hemor- 
rhagic stools. Occasionally edema is observed, especially in the ankles. With 
great blood loss dissolution is very rapid and the infant perishes at the end 
of the first week. In some cases the course is somewhat slower, but death 
is rarely prolonged beyond a fortnight. The hemorrhages are not always 
prominent; on the contrary, they may be absent and death occurs with the 
symptoms of a constantly progressive debility or perhaps may be so sudden 
that an accident is thought of, for example, suffocation. 

Fatty degeneration is generally regarded as an extremely rare disease. 
We must, however, agree with Eunge that some of the cases are obscured 
by designations such as asthenia, umbilical hemorrhage, melena. 

In the differential diagnosis the primary debility, the asphyxia, and espe- 
cially, in contrast to melena, the involvement of various organs and tracts 
in the hemorrhage, are of value. Pathologico-anatomically the diagnosis can 
only be made by exclusion. The suspicion of poisoning by arsenic or phos- 
phorus will rarely come into question. Most difficult is the differentiation 
from general septic infection. In this connection it has already been re- 
peatedly emphasized that diseases of the umbilical wound and of the navel 
vessels are conclusive. Without a demonstrable primary focus the decision 
must devolve upon minute bacteriologic investigation. Hecker has already 
called attention to the similarity of the lesions with those arising from suffo- 
cation. This is based particularly upon the cyanosis, the decreased amount 
of air in the lungs, and the ecchymoses. The microscopic demonstration of 
more or less extensive lesions in the organ is especially important. 

Etiologically it is now generally accepted that the condition is due to the 
consequences of general infection, but its specific nature is still obscure. 



120 DISEASES OF THE NEW-BORN IN THE FIRST DAYS OF LIFE 

For the reason that with the introduction of asepsis and antisepsis the 
affection lias almost entirely disappeared, most authors incline to the view 
that the pathogenic principle belongs to the group of septic infectious 
agents. 

The prognosis is highly unfavorable — fatal. Acute fatty degeneration 
has always terminated in death. 

Treatment. — In prophylaxis the prevention of septic infection is of most 
importance. 

The treatment must be entirely symptomatic, namely, control of the 
hemorrhage from the nose, mouth, and intestinal canal by the employment 
of styptic remedies, especially of gelatin; improving the general condition 
by the best possible nourishment (breast-milk), and by heat. Finally, relief 
of the collapse by analeptics (wine, brandy, ether). All of these measures, 
however, are usually without result except to temporarily postpone the lethal 
termination. 

WINCKEL'S DISEASE 

This affection, first described by Winckel, in which also the symptom- 
complex shows a tendency to hemorrhage, is characterized clinically by the 
appearance of hemoglobinuria. The first recognition of the disease was in 
the Dresden Obstetric Clinic as an endemic affection and within a month 
it had attacked 23 newly born infants, i. e., 25.5 per cent, of all the children. 
The affection usually appeared on the fourth day of life with marked cyanosis 
and intense jaundice. The color of the urine was bluish brown or olive green 
and contained large quantities of hemoglobin, some albumin, epithelium from 
the pelvis of the kidney, and granular casts. The temperature, at first normal 
or but slightly above (38.1° C. — 100.5° F.), soon became subnormal. The 
respiration was more or less accelerated but the pulse was seldom rapid. 
Vomiting or diarrhea occasionally occurred. Upon the removal of a few 
drops of blood for examination only a thick brownish fluid was discharged 
from the wound, which under the microscope revealed a decided increase of 
leukocytes in addition to many pigment granules. Most conspicuous was 
the rapid loss. of strength: the infant soon became apathetic, somnolent, and 
as a rule perished in thirty hours, occasionally in nine or twelve hours, from 
convulsions. Of the 23 cases only 4 recovered. At the autopsy the kidneys 
showed in particular the signs of a hemoglobin infarct and in addition an 
inflammatory swelling. The cortical substance was broadened, red — or 
black brown, and permeated with punctiform hemorrhages; in the pyramids 
this discoloration appeared striated. The uriniferous tubules were filled with 
granular pigment (hemoglobin). Similar collections of pigment were found 
in the spleen, which was usually enlarged, hard, and of a deep, dark red 
color upon the smooth cut surface. Among the other lesions there must be 
mentioned the wide distribution of punctiform hemorrhages in the internal 
organs, serous and mucous membranes, swelling of Peyer's plaques and of 
the mesenteric glands, as well as parenchymatous inflammation, i : e., fatty 



CONSTITUTIONAL DISEASES 121 

degeneration of the myocardium and of the liver. Disease of the navel ves- 
sels was found only in one case. 

Concerning the question of a causal development, notwithstanding all effort 
and investigation von Winckel was unable to reach a conclusion. Correspond- 
ing observations were later reported in very limited numbers (Sandner, Stre- 
litz, Baginsky, Kamen). The view of most authors is that Winckel's disease 
depends upon the results of a general infection, the damage being revealed 
particularly by the destruction of the erythrocytes. The nature of the causa- 
tive agent, whether a definite microorganism or several, has not yet been 
determined. Strelitz found streptococci in his case but does not believe they 
were responsible for the affection. His observation is particularly interest- 
ing as the case was a sporadic one, occuring two days after a ritual circum- 
cision. Kamen holds the bacterium coli communis responsible, which he was 
able to cultivate from the well-water employed in washing the mouth. When 
this water was no longer used the distribution of the disease ceased. Ahfeld 
quite properly propounds the question, why the children were not previously 
affected since the same water had been employed. 

Treatment. — Therapeutically the same measures are indicated as have 
been detailed for the treatment of melena. 



THE FEEDING OF CHILDREN 

By AD. CZERNY, Breslau 

When the feeding of children is made the theme of an article it must be 
associated with the thought that it differs materially from the nourishment 
of the adult. Therefore it is possible to consider the technic of feeding only 
after a consideration of the peculiarities of the child, on the one hand, and, 
on the other, after we determine the age at which the food of the child and 
of the adult become equal. 

Experience has taught that a food which is nutritive and proper for an 
adult may produce disease in the first years of life; as the child grows older 
this condition does not usually occur in the same form and intensity. Many 
attempts have been made to study the function of the various divisions 
of the intestinal tract and its adnexa, and, by a comparison of the 
results, to draw conclusions of their proportions in the child and in the adult. 
These investigations, although very interesting, have shown merely that in 
the child there are quantitative but not qualitative differences in the function 
of the intestinal canal and its adnexa. Examinations of the saliva, the gastric 
juice, the pancreas, etc., of infants have led to the institution of special diete- 
tic rules, wherein the facts that have been obtained are especially considered: 
but the success which has resulted from the employment of these measures 
has not been such as to justify us in assuming that the essential object has 
been attained. 

A critical review of all researches relating to the function of the intestinal 
tract and of its glands would lead to the logical conclusion that the nutrition 
of the child would differ only quantitatively from that of the adult, with the 
one exception that the food would have to be liquid so long as the child is 
without teeth. The food of an adult, however, would make a child ill, even 
if administered in a quantity corresponding to the body weight. This proves 
that the child lacks certain protective measures which have as yet not been 
demonstrated by research. In the consideration of nutrition we must first 
ascertain the functions of the intestinal tract and the transformation of food 
in this area, also the processes of resorption and their extent. Not less im- 
portant is the destiny of the food in the intermediary metabolism as regards 
its nutritive effect. The peculiar relation of the latter to nutrition enables 
us to understand the difference between the infantile organism and that of 
the adult. In contrast to the processes in the intestinal tract they have been 
considered but little and studied less. To make these relations clear I must 

122 



THE FEEDING OF CHILDREN 123 

state, as an example, that for a long time it was thought that the unsatis- 
factory results from the feeding of cow's milk to children were due to the 
"difficulty of digestion" of the casein in the milk. The more this subject 
was investigated the more evident it became that the digestion of casein, if 
we understand by this merely the processes in the intestinal tract and its 
absorption, was sufficient in both healthy and sick children. Therefore, in- 
sufficient absorption alone cannot be responsible for these poor results. If 
we inquire how much of the absorbed casein is retained in the organism, i. e., 
utilized in the growth of the body, it is shown that the retention is by no 
means parallel to absorption, but that, with very good absorption, there may 
be insufficient retention. 

The insufficient knowledge of the intermediary metabolism has led us 
astray in our search for the protective agency in the nursling, and the dangers 
which improper food is liable to produce in children. 

The investigations of the intermediary metabolism in the child, which 
will be considered later, have already placed us in a position to choose some 
foods and determine their amount, but by no means have they brought about 
a theoretic construction of a food that, in all of its constituents, is suitable 
alike for healthy and sick children. Especially in this realm experience has 
proved that theories, apparently well founded, often produce unexpected 
results, or even quite an opposite effect, when applied to the child. 

We are compelled to consider the nutrition of infancy as a separate subject 
not so much because of our inadequate knowledge of infantile metabolism, 
but because children surfer more readily and more often from disturbances 
of nutrition than adults, and that these derangements are dependent upon 
the nature and quantity of their food. 

Clinical experience is the only factor by which we may determine when 
the food of the child may equal that of the adult. As I shall demonstrate 
hereafter, we do not at present possess a theoretic foundation for the determi- 
nation of the age limit. We have contented ourselves with the belief that 
dentition is the time when the child begins to eat solid food; therefore, at 
the end of the first year it may be accustomed to the food of adults, although 
it still receives milk. Such opinions are not scientific and are not even based 
upon experience. Careful investigations of the functions of the intestinal 
tract and its adnexa, and of metabolism, have been made only in nurslings 
and, therefore, do not permit us to determine a period at which the food of 
the child may equal that of the adult. The special predisposition of the child 
to nutritive disturbances does not disappear with the termination of the first 
year of life, as might be assumed from most diet formulas, but at the end 
of the second year. From that period the digestive disturbances are the same 
as those of later life. 

In designating the end of the second year as the time at which the nutri- 
ment of the child and of the adult may be considered in common, I refer 
only to healthy children. It is obvious that with the appearance of disease 
this period must be deferred. 



124 THE FEEDING OF CHILDREN 

Separate consideration has been given to the nutrition of the sick and 
the well among adults, but, unfortunately, the opposite is the case in the 
discussions of infant feeding. The most varied foods have been administered 
alike to healthy and sick children; partly because of the inequality of the 
food and partly in consequence of the variation in dose, contradictory opin- 
ions have been maintained. This has given rise to very dissimilar views in 
teaching. The lack of discrimination of food for healthy and sick children 
arises from the fact that the mother's milk is the most suitable food for 
both the ill and the healthy infant. If the subject of nutrition of children 
is to be made clear, we must begin by a separate consideration of these two 
entirely different problems. 

In the following I shall treat only of the nutrition of the healthy child. 
The food must be of a nature to permit normal bodily and mental develop- 
ment, in so far as these are dependent upon the food, and to exempt the 
child from functional disturbances and from diseases due to faulty nutrition. 
This result can be attained only in children born of middle-aged, healthy 
parents, carried to full term and free from serious deformities, and who 
weight at least 3000 grms. at birth. In the following dissertation these are 
designated normal children. Equal results cannot be attained in weaklings or 
children of premature birth, or in the offspring of parents who are greatly 
debilitated, too young, or very old, notwithstanding the same food is ad- 
ministered. This fact must be borne in mind so that the food shall not be 
considered responsible for unsatisfactory results. Subsequent explanations 
will refer only to conditions in healthy children. 

The best result is likely to be attained if the child is nourished from 
birth with the mother's milk, provided this is furnished in proper amounts 
and at definite times. Great stress must be laid upon this latter point, because 
the feeding of the mother's milk does not in itself insure the normal develop- 
ment of the child. Even in the breast-fed child excessive feeding may pro- 
duce severe diseases which are so common in the infant that is artificially 
nourished, and which are so difficult to relieve. The younger the child, the 
greater is this danger. Many are made ill from breast nourishment during 
the first few days of life or even on the first day. This may be avoided if 
the new-born infant is not fed at all upon the first day, and in the following 
days food is given but three or four times in twenty-four hours. Afterward, 
five or six feedings in the course of the day are sufficient. These directions 
are not given arbitrarily, nor do they follow any authority, but they are 
derived from observation of normal breast-fed children who have had their 
food when they wanted it, and not according to the advice of a physician. 

The first day requires special observation. At this time an important 
change takes place in the intestinal tract, of which no analogy is observed 
in later life: The sterile intestinal tract is permeated by microorganisms 
(Breslau, Escherich, Popow, Schild). As it is impossible for us to know 
whether we may or may not favor this process of invasion by the administra- 
tion of food, it is advisable not to feed the child or to give only some in- 



THE FEEDING OF CHILDREN 125 

different fluid, such as weak tea sweetened with saccharin. Sugar should be 
avoided as it produces fermentation. It is a noteworthy fact that among 
savages it is customary, probably the result of experience, not to give the 
new-born any food for the first twenty-four hours. 

Passing over the first days, when healthy children take very few meals 
spontaneously, it will be found that five feedings in twenty-four hours, or 
at most, six feedings, are sufficient. This leaves intervals of three to five 
hours between the individual feedings. Therefore the mother or the nurse 
should be instructed that the child is not to be put to the breast oftener than 
five or six times in twenty-four hours, the minimum interval in feeding to be 
three hours. Eestlessness between times is the sign of a disturbance of 
nutrition, and indicates a prolongation rather than a shortening of the period 
between the feedings. 

If we follow the foregoing directions we may count upon normal develop- 
ment from breast feeding, and the physician need decide then only how 
long the infant is to have exclusive breast nourishment. In some cases this 
period is self-evident, for the secretion of milk is no longer sufficient for the 
development of the child. It must be stated emphatically that insufficiency 
of food can never be determined by the arrest or decrease of the weight alone, 
especially if either of these conditions occur suddenly, for they are usually 
evidences of a disturbance in nutrition. The only infallible symptom of 
deficient secretion of milk is an apparent constipation; the child, who has 
up to this time had one or two yellow stools daily, now has a movement only 
once in thirty-six or forty-eight hours, and, if the deficiency in food is great, 
the feces are no longer of the characteristic yellow color, but are tinged a 
light brown or green. I have designated this apparent constipation as there 
is merely a diminution of the feces because of insufficient food. It is neces- 
sary to mention that in this condition the child is not especially restless. 

If in the first six months, the breast proves inadequate, an adjunct to 
the food is indicated. If this occurs later than six months there should 
be a gradual weaning of the child. 

Should the secretion of milk be sufficient in the first six months, the ques- 
tion arises, how long should the child have exclusive breast nourishment. 
Observation of children who have had exclusive breast feeding for a year 
or more has shown that this prolonged exclusive nursing does not yield the 
best results. As a rule, these children are exceedingly fat, so that an equal 
accumulation of fat later in life must be regarded as pathologic; further- 
more they are usually pale. Whether this is the consequence, as is asserted 
by Bunge, of an insufficient amount of iron in the milk has not been absolutely 
determined. In these children there is sometimes well-developed rachitis. 

Experience has taught that children aged six months, and older, not only 
assimilate food other than milk but that they develop better than from ex- 
clusive breast feeding. At the end of six months a normal child should have 
additional food, and in the course of the following three to six months should 
be weaned. This rule is by no means so invariable that other considera- 



126 THE FEEDING OF CHILDREN 

tions need not be taken into account. For example, it is not advisable to 
wean the child during the hot summer, when fresh and pure cow's milk is 
often difficult to obtain; under such circumstances the period of weaning 
may be deferred somewhat. On the other hand, another pregnancy — not the 
appearance of menstruation — may require an earlier abandonment of breast 
feeding. 

If a child aged six months is to be weaned, my method is as follows: 
Once in twenty-four hours substitute a soup for the breast milk. This should 
consist of a meat broth (from a quarter of a pound of meat), to which 
sufficient fine grits is added to give the soup a pappy consistence. This soup 
is to be prepared in the same manner as for adults, but it should contain 
no fat and must be prepared from fresh meat and bones, not from meat 
extracts. The kind of meat is immaterial; we cannot scientifically demon- 
strate the advantage of pigeon or of mutton broth over beef as there are 
no reports regarding the assimilation and absorption of gelatine in the in- 
fantile organism. The broth must not be too concentrated, otherwise the 
child is likely to reject it. As a carbohydrate I prefer grits on account of 
the stimulating influence of the cellulose upon intestinal peristalsis. 

The early addition of carbohydrates is justified, since experience has shown 
that during the transitional period to a mixed diet they are the most serv- 
iceable adjunct to milk. 

With this change in the food we may continue breast feeding for several 
weeks, or for some months if necessary (for example, during the hot sum- 
mer). The substitute meal of soup is given uninterruptedly throughout the 
period of weaning. At the beginning of this period a second meal is added 
which should consist of animal milk thickened with some cereal, in the same 
amount and concentration as would be administered to a normal, artificially 
nourished child of the same age. As I shall refer again to this admixture 
of milk I will only say here that several days should intervene before there is 
a further change of food, provided there is no reason for a rapid weaning 
of the child; in addition, the breast and artificial food must be given alter- 
nately, to prevent an accumulation of milk in the breast. Should this con- 
dition nevertheless arise, the superfluous milk must be drawn off to prevent 
a premature arrest of the secretion. It is advisable not to endeavor to in- 
crease the weight of the child during the weaning period, and, if this should 
occur, to limit the amount of food, as the danger of hypernutrition' is par- 
ticularly great during this time, although serious consequences may not 
present themselves until some weeks have elapsed. 

In the foregoing I have assumed that the mother is capable of supplying 
her child with the necessary amount of nourishment. The conditions are 
analogous if a wet-nurse is employed from the birth of the infant. I shall 
not discuss all of the requirements which have been stipulated, justly or 
unjustly, in the choice of a wet-nurse, but shall merely emphasize the fact 
that we are as yet unaware of variations in the milk of different women which 
are of importance in the welfare of the infant. I agree with Heubner, who 



THE FEEDING OF CHILDREN 127 

believes that a chemical examination of the milk is without value in the 
choice of a wet-nurse. 

In German literature the natural feeding of the infant is contrasted with 
the artificial, that is, with animal milk or other substitute. The French 
pediatrists have a middle course which they designate "allaitement mixte." 
This term is unknown to German authors, and even the language contains 
no such expression. Nevertheless, this form of feeding is fully justified, and 
consists in the addition of animal milk when there is an insufficient supply 
of breast milk. It is certain of success, particularly when instituted at birth, 
and is to be preferred to artificial feeding, which is a hazardous undertaking. 
The belief of many physicians that the dangers of artificial feeding are now 
reduced to a minimum has arisen, in my opinion, from the fact that reports 
have included the favorable results obtained in children who have been fed 
from the first days or weeks of life with breast milk in combination with 
artificial nutrition. The greatest danger of artificial feeding arises when 
this method is instituted from birth — a danger which decreases decidedly 
if the infant has been fed, even for two or three weeks previously, from the 
breast. Therefore it is necessary to make every effort to have the mother 
nourish her child and, when her secretion of milk is inadequate, to institute 
allaitement mixte, and thus avoid an exclusive artificial feeding. 

Allaitement mixte (mixed feeding) is justified only when an examina- 
tion of the child reveals that the secretion of milk is actually insufficient. If 
this method is carried out properly, many a mother will, after a time, be able 
to nourish her child exclusively, even though lactation began slowly and only 
gradually increased. For this reason mixed feeding should always be pre- 
ferred. If we conclude, from the deficient increase in flesh, from the weight 
of the child before and after a breast feeding, or from the scant brown or 
greenish stools, that the mother's milk is inadequate, we first administer 
animal milk of the same concentration and amount as would be given to a 
child of the same age who is artificially nourished. We should, however, ob- 
serve that the same difficulties must be produced by the bottle from which 
the infant is fed as would arise from a breast with a meager supply of milk, 
for otherwise the child would very soon refuse the breast, which cannot 
satisfy its hunger. 

Experience teaches that in many children the addition of a single artificial 
meal is enough for satisfactory growth and development. If it is found, 
after a few days, that one artificial meal is inadequate, a second, and, if 
necessary, a third is added. It is well to proceed slowly and cautiously, be- 
cause the secretion of milk accumulates more rapidly the oftener the child 
has recourse to the breast. By a too rapid addition of artificial food lactation 
may cease in consequence of an insufficient withdrawal of the milk. By means 
of allaitement mixte the child may be satisfied with the mother's milk if we sub- 
stitute one artificial feeding. If a repetition of the substitute meal in the 
twenty-four hours is necessary, we must alternate between artificial and natural 
feeding so as to prevent immoderate accumulation of milk in the breast. 



128 THE FEEDING OF CHILDREN 

As there is no equivalent of the mother's milk for the first six months 
of life, I prefer to continue the mixed feeding (allaitement mixte) for that 
period, even should the increase of the child's weight be slightly less than 
the normal. 

When it is impossible for the mother to nurse her child, only animal 
milk can be considered as a substitute for breast milk in the first days of 
life, and particularly the milk of the cow, the goat, the mare and the ass. 
When I refer to the substitution of animal milk for woman's milk, I ignore 
the fact that animal milk is usually employed after it has been modified. As 
a matter of fact but few infants are fed unaltered animal milk. Such at- 
tempts have been made upon a large scale only in Milan and Paris, and the 
results have not sufficed to form a conclusive opinion of the value of the 
method; nevertheless, in the cities mentioned the feeding of raw milk has 
not been permanently adopted. In the following I shall refer only to cow's 
milk, because this is the only animal milk of which we have a sufficiently 
practical experience for its professional employment. 

Observations in regard to the nutriment value of unaltered cow's milk 
are insufficient. Cow's milk is always fed to children after it has been heated. 
This produces a change whereby it can no longer be compared with breast 
milk as a food, even though we may concede that the constituents of both 
are almost identical. 

Lunin has shown by animal experiments that unaltered animal food is 
of value in nutrition, and, although we are at present unable to explain 
this fact, it should deter us from altering the physical and chemical con- 
stituents of animal milk without some imperative reason. 

Nevertheless, we are compelled to boil cow's milk, or at least to heat it, 
for the purpose of infant feeding, because the milk is liable to become infected 
by microorganisms, which are by no means indifferent, in the course of its 
transmission from the udder to the child, i. e., in milking, transportation, 
etc., or the milk itself may contain pathogenic organisms, such as tubercle 
bacilli. An empiric rule is to boil the milk to prevent decomposition; since 
we have found an explanation of this fact in the advance of bacteriology, and 
have appreciated its importance, we now speak of "sterilization" in infant 
feeding. 

Stress must be laid upon this subject, because there have been many phy- 
sicians (there are yet a few) who regard sterilization of cow's milk in infant 
feeding as an epoch-making innovation, and believe that all the difficulties 
of artificial nutrition have been overcome by this process. That the results 
of artificial feeding are not conspicuously improved by the use of sterilized 
milk has been attributed by most observers to the incomplete methods of 
sterilization. In my opinion, the lack of success of sterilization may be 
referred to the fact that, in former times, children were fed with boiled milk, 
and, therefore, this later method has not produced any essential change. How- 
ever, valuable knowledge has been gained from the observation of children 
who have been brought up by sterilized cow's milk, for we have learned not 



THE FEEDING OF CHILDREN 129 

to over-estimate the importance of the microorganisms which are present in 
the milk, as has been done so frequently. If it were true that the dangers of 
feeding with cow's milk are due alone to the microorganisms which it contains, 
there would have been, at least in those institutions in which sterilization 
has been strictly observed, a change in the results of artificial nutrition as 
remarkable as was observed upon the introduction of antisepsis in surgery. 
This, however, has not been the case. 

After the foregoing remarks a special description of the various methods 
of sterilization would be superfluous. Therefore I shall merely state that 
brief heating (not to exceed ten minutes), followed by rapid cooling, and 
preservation of the milk at a maximum temperature « of 10° C. (50° F.) for 
not over twenty-four hours, is sufficient for ordinary requirements. It is much 
more important to note in how far the cow's milk has been altered by the 
action of bacteria before it is boiled. An essential requisite is this: The 
milk which is to be used for infant feeding should be as fresh as possible, 
and retain its natural alkalinity. This requirement, which has not been 
sufficiently emphasized, is rarely fulfilled during the summer months in large 
cities. A test of the alkalinity offers a simple and sufficient control of the 
purity of the milk, as the acid-producing bacteria develop much more rapidly 
than the other microorganisms. The degrees of acidity prescribed by the 
Sanitary Commission in Germany for marketed milk are much too high for 
milk that is to be used for infant feeding. The addition of alkalies to com- 
pensate for the acid formation which has taken place in the milk has proven 
unserviceable in my experience. 

The years during which the sterilization of cow's milk has been considered 
essential in the technic of infant feeding have further enriched our knowledge. 
At first the milk was either boiled too long (up to three-quarters of an hour) ; 
or, in order to prevent too great a loss to the manufacturer, it was sterilized 
by repeated heating, sometimes even to temperatures far above 100° C. (212° 
F.), and then kept for weeks or months as old, permanent milk (Dauermilch). 
Experience has proved that children who have been fed for months exclu- 
sively with cow's milk prepared in this manner develop Moller-BarloVs dis- 
ease (infantile scurvy). I have observed a number of children in whom this 
affection has developed after they were fed with Gartner's or Backhaus's 
milk, who recovered from the malady after the substitution of fresh boiled 
milk. Various pediatrists (v. Eanke, Escherich, and others) have asserted 
that, notwithstanding an extensive experience in feeding with intensely 
sterilized milk, they have not seen a case of Moller-Barlow's disease: These 
reports do not annul my own observations, for there are numerous other inves- 
tigators (Heubner, v. Starck, and others) who state that the appearance of 
this disease requires continuous feeding with greatly heated milk for a period 
of seven to ten months. The number of cases which fulfill this requirement 
is fortunately not large, as in most children, for various reasons, the food 
is altered earlier, or some addition is made to the diet, which counteracts this 

damage. 

10 



130 THE FEEDING OF CHILDREN 

To avoid the deleterious effects of cow's milk, just described, Pasteuriza- 
tion has been proposed, as by this means the most dangerous microorganisms 
of cow's milk, such as tubercle bacilli, are destroyed. The practical results 
of this method, which are at hand, do not show a noteworthy influence upon 
the morbidity and mortality of infants. 

In regard to the quantity of cow's milk which an infant should receive, 
and the nature and manner of its preparation, several fundamental principles 
have been determined from the observation of children fed normally at the 
breast. My general rule in artificial nutrition is that from the second week 
of life a child should have but five meals in twenty-four hours, that is, there 
should be intervals of four hours between the feedings, with one or two longer 
pauses during the night. Upon the first day no nourishment should be given ; 
upon the second day there should be two feedings; upon the third day three 
feedings, etc. ; therefore, only from the fifth day are five meals to be adminis- 
tered. A child should never be awakened from sleep, even if a meal is thereby 
omitted. 

This method is based on the fact that the number of meals mentioned 
corresponds to the number which normal breast children take spontaneously; 
furthermore, in artificial nutrition a longer time is required to empty the 
stomach and to develop free hydrochloric acid than in children fed with 
breast milk. In my experience such a regime offers less danger than the 
more frequent meals recommended by some specialists, as these cannot be 
taken by many infants without succeeding harm. 

As cow's milk as such is not identical with breast milk in its chemical 
composition, and, in consequence, an equal amount of these foods does not 
represent an equal nutritive value, numerous methods have been proposed 
for the estimation of the amount of cow's milk required for a child in tiventy- 
four hours. All such calculations are founded on the amount of breast milk 
which normal children take spontaneously. That the physician or the mother 
may decide whether the child requires more or less milk than the average 
amount which has been proposed is self-evident. But these figures are lacking 
in other respects. In the first place the basis of these figures has been de- 
termined by weighing normal breast fed children, but they by no means rep- 
resent the necessary or correct quantity of food for the child. Children fed 
at the breast often become so fat that the same intense accumulation of flesh 
at any other age would be regarded as pathologic. A nutrition which pro- 
duces excessive fat can scarcely be regarded as necessary. We must conclude 
that such an infant receives more nourishment than it requires. Cramer has 
made mention of this and has accumulated observations which should aid us in 
the decision of the essentially important question, how little breast milk is 
necessary for the normal growth and development of a child. His investiga- 
tions are not sufficiently extensive to solve the problem, but they have shown 
that the quantity of breast milk which a child requires is much less than that 
which has heretofore been regarded as a standard, and that, therefore, the 
amounts of milk previously calculated for infants have been excessive. 



THE FEEDING OF CHILDREN 131 

This would be immaterial could it be shown that with moderate hyper- 
nutrition with cow's milk there would be as little apparent damage to the 
organism as is observed under similar circumstances with breast milk. But 
such is not the case, for while with the latter there is at most a marked 
accumulation of fat and a discharge of the superfluous food through the 
intestine, a hypernutrition with cow's milk usually produces constipation, 
anemia, muscle weakness, or other obvious symptoms of disease. 

Therefore I maintain that a child which must be nourished artificially 
should receive the smallest quantity of food that is necessary for a proper 
development of the body. Further, if there is a sufficient increase in the 
body weight, the amount of food must not be increased as the child advances 
in age. This latter point usually is not observed, and failure of artificial 
feeding is the result. 

As there are essential differences in the quantitative as well as in the 
chemical composition of individual constituents, it is not enough to give the 
same amount of cow's milk as would be consumed by a child at the breast. 
Some authorities (Budin, Chavane, Eothschild) advise undiluted cow's milk 
from birth. This method has not been tested sufficiently to permit of its 
general adoption. Although some infants may thrive with such a diet, we 
do not know how such feeding would be borne by the majority of children, 
and since there is no standard dosage of undiluted cow's milk the danger of 
hypernutrition is great. Under no circumstances can a nursling take the 
same quantity of cow's milk as of breast milk without any injurious effect. 

To avoid hypernutrition with cow's milk, on the one hand, and not to 
limit the ingestion of water by the necessary restriction of the amount of 
milk, on the other hand, the necessity for dilution arises. Attempts have fre- 
quently been made to refer the evil results of feeding with diluted cow's milk 
to dilution which does not equalize the quantitative variation of breast milk 
and cow's milk. Investigation of their chemical differences has led to an 
over-estimation of those differences in many ways, for it is possible for healthy 
children to thrive with simple dilutions of milk. If it were necessary to 
calculate fractional percentages of casein, albumin, fat, etc., in the artificial 
food of a healthy child, then the morbidity and mortality would be decidedly 
greater than it is in fact, because of the existing difference of opinion of 
physicians and the circumstances that many children are artificially nourished 
without professional advice. 

A scientific foundation for dilution of milk appeared to be given by an 
estimation of the nutritive worth of food according to its calory value. I 
say purposely that it appeared to be given, for food must not only fulfill the 
heat requirement of the organism, but it has other essential objects which 
sometimes are forgotten, since we have accustomed ourselves to look upon 
the calory value of a food as of first importance. We must select a food for 
the infant which contains the necessary calories for the organism, but this 
must not be by any means the only or essential factor in our estimation of 
the food. In the first place, practical experience with nutritive flours has 



132 THE FEEDING OF CHILDREN 

shown that they do not supply permanently the most important heat-pro- 
ducing constituents of food (carbohydrates, fat, and proteids) in isodynamic 
amounts without injury to the child; secondly, we have not yet been able 
to estimate how large a part of the combustive material is lost to the infant 
organism by insufficient absorption or oxidation, by fermentation in the intes- 
tine, etc. Finally, as was mentioned previously, we have no standard figures 
for the calory requirement of the nursling more than we have for the amounts 
of food that are necessary. 

The results of infant feeding with simply diluted cow's milk are so lack- 
ing in uniformity that experimental investigations in this direction have never 
been abandoned. As it is my object to describe only the feeding of healthy 
children, it does not appear necessary to enter upon a discussion of the 
various procedures for the modification of cow's milk which have been sug- 
gested, but which for the most part require a more thorough test. I must, 
however, mention two methods which appear to me to be important. 

Gartner has offered a simple and serviceable solution of the problem of 
equalizing the amounts of albumin, sugar and fat in cow's milk with, those 
of breast milk by the introduction of his so-called fat-milk (Fettmilch). 
As experience has already shown, this is particularly useful for infants during 
the first month; unfortunately, in some cities in Germany, such as Breslau, 
it is boiled so long as to produce various deleterious effects from its exclusive 
use, especially Moller-Barlow's disease. 

Gartner devoted special attention to the total albumin contents, but other 
investigators attempted to produce in cow's milk the proportion of albumin 
to casein that is found in breast milk. For this purpose they utilized whey 
instead of water. This theory, introduced by Kehrer, was employed later 
with Gartner's centrifugation process by Backhaus, Vigier and Monti. 
According to experience, normal children become fat in the first month from 
these mixtures, but whether the whey-milk is more serviceable than Gartner's 
fat-milk, and whether the theoretic considerations are correct, remains to be 
proven. 

My method for the artificial nourishment of children from the first week 
of life is as follows: Cow's milk is first diluted in the proportion of one 
part milk to two of water. Of this mixture I have 100 c. c. prepared for 
each meal, to which is added a teaspoonful of milk sugar. For the first 
period I choose a milk reach in fat or cream 1 , but later a milk poor in 
fat is preferable. This change in the quality of the milk is due to the great 
dilution which is made at first. With a milk already poor in fat this dilu- 
tion would be too great, but in older children such a result need not be 
feared, since a larger proportion of pure milk is then administered. The 
milk sugar is added to produce somewhat the normal processes of fermenta- 
tion in the intestine, as well as to cause a better retention of nitrogen from 
the small amounts of albumin which are introduced. Heubner, Hoffman and 

1 This should be obtained by skimming, not by centrifugation, so that the percent- 
age of fat will not be too high. 



THE FEEDING OF CHILDREN 133 

Soxhlet have attempted to determine the amounts of milk sugar which are 

necessary to give a diluted milk the same calory value as an equal quantity 
of breast milk. It is obvious that for each dilution of milk a special addition 
of milk sugar is necessary if this requirement is to be fulfilled with exact- 
ness. However, as has been emphasized, an exact dosage of the individual 
constituents of the food is not necessary in the nutrition of a normal child, 
and as the estimation of the calory value of the food by no means represents 
an absolute method, I believe it to be a sufficient rule that to each meal a 
teaspoonful of milk sugar should be added. I select milk sugar because 
comprehensive investigations regarding the deleterious effects of various 
carbohydrates (Keller) have proved that it is most serviceable for children 
during the first months of life. For the same reason I avoid the employ- 
ment of other sugars or carbohydrates during the first weeks. The adminis- 
tration of 100 c. c. as an individual meal during this time is sufficient even 
for robust children, while debilitated children may have a smaller allowance. 
That from the end of the first week there should be five meals in twenty-four 
hours has already been emphasized. 

As a criterion for the increase of the quantity of milk, I advise that not 
before the end of the first year should a child have a liter of milk in twenty- 
four hours, and never more than this. The increase should be very gradual, 
and by this rule every mother will be able to calculate how much milk her 
child should have at a definite age. 

These milk rations, which certainly may appear extraordinarily small, 
are not sufficient for many children in the first weeks or months of life to 
produce good nutrition, even with the addition of milk sugar; therefore, 
from the fourth month, instead of increasing the quantity of milk sugar, I 
add flour. Careful observations (Gregor), as well as my own experience, 
have shown that by this early and systematic administration of flour the 
danger of rickets and scrofula is not increased, but lessened. The cereals 
which I employ for this purpose are wheat flour, oat flour and corn starch 
(Mondamin). I do not agree with many authors, who assert that it more 
advantageous to employ dextrinous flours. The manufacturing chemist has 
attempted to solve this requirement by the preparation of nutritive cereals 
for infants. Here I see but one disadvantage for the children. The more 
quickly and completely the flour is transferred into sugar the more dangerous 
it is to the infant. If the rapid and complete resorption of sugar were the 
necessary factor, then a food consisting of sugar should furnish the best re- 
sults, for it would save work for the intestine. Experience, however, has 
taught the opposite: While flour is well borne, sugar has a deleterious ef- 
fect. My explanation of the favorable influence of flour, in which a slow 
saccharification in the process of digestion is possible, is that the absorption 
of water, due to the sugar, occurs more slowly and is more readily compen- 
sated for by the organism. The formation of acid by fermentation is more 
moderate, and at the same time is less effective because it occurs more slowly. 
In this moderate extent the processes of fermentation are rather calculated to 



134 THE FEEDING OF CHILDREN 

oppose constipation, which is so liable to occur in exclusive feeding with 
cow's milk. 

As in the case of children nourished at the breast, so also with an artifi- 
cially fed infant: After the sixth month we give a daily meal of meat broth 
with grits. To prevent an increase of the number of meals the surplus 
amount of milk is distributed among the other four feedings. Toward the 
end of the first year, and, in very robust children, even from the tenth 
month, I permit a few teaspoonfuls of some vegetable, to be given imme- 
diately after the broth with grits, such as spinach or carrots, which have 
been pressed through a sieve. This vegetable diet, which should be begun 
during the first year, forms a very important constituent in the nutrition of 
the child in the second year; at that age it is the main source of alkalies and 
iron, and, as these vegetables are rich in cellulose, they have a favorable ef- 
fect upon intestinal peristalsis. 

As I have already emphasized, one of the most important requirements 
in artificial nutrition, even of the healthy infant, is to proceed very slowly, 
and gradually to increase the amounts of food provided. We will know if 
the food administered is insufficient by the scant increase in weight and by 
the composition and amount of the feces. 

Even in adults we differentiate between great and small eaters. This 
varying apparent requirement of different individuals cannot be referred 
to heredity but arises gradually from the nature of nutrition in the first and 
following years of life, either in that the children are given superfluous 
quantities of food, or that they are given food of little nutritive value, and 
therefore require larger amounts. My experience has taught that those in- 
dividuals who are large eaters are feebler in their development and in their 
resistance to infectious processes than those who are moderately nourished. 
I must, therefore, add that I determine the volume of food by the adminis- 
tration of 100 c.c. to children during the first weeks of life, and increase 
gradually, until at the end of the first year the quantity of food amounts to 
about 250 c.c. The average size of the individual meal may be readily de- 
termined from these extremes, just as in the composition of food. 

Thus far we have been treating of the requirements of healthy children. 
I have already stated that a strict separation of these from children who are 
ill is necessary for an understanding of proper and improper nutrition. No 
one would claim that a food is useless because an adult with gastric disease 
could not digest it, nor would any one insist that a diet suitable for such a 
patient is necessary for a healthy person. Only in the nutrition of children 
is the fact usually overlooked that normal, healthy children differ essentially 
in their food requirement from those who are ill. 

I have, therefore, believed it best throughout to determine the require- 
ment of the healthy child, and must remark again that the nourishment de- 
scribed here is proper only for infants who are born healthy and remain so. 
It is necessary to know that almost every derangement of nutrition will leave 
sequels which may persist for a long time after the disappearance of the 



THE FEEDING OF CHILDREN 135 

obvious gastrointestinal disturbances, and a child thus affected will not 
thrive from a food that is the same, quantitatively and qualitatively, as that 
of a child who was never ill. It cannot be emphasized too strongly that the 
nourishment I have advised is only proper when the infant is always free 
from gastrointestinal derangements. 

It is the opinion of most authors that from the end of the first year a 
child should gradually have the food of adults. Some physicians advise a 
trial of meat or eggs even earlier than this. In my judgment these views 
lack sufficient foundation. The child requires a special food so long as there 
is a tendency to disturbed nutrition from causes which are apparently insig- 
nificant. As experience has taught, this labile equilibrium of the nutritive 
condition does not cease with the end of the first year, but terminates gradu- 
ally toward the end of the second. The physician has almost daily oppor- 
tunity to observe cases in which a good result of nutrition during infancy 
is more or less destroyed by improper food in the second year of life. It is 
true that during this time there is a change in the character of the nutritive 
disturbances, which become less dangerous as the age of the child increases, 
but only after the end of the second year is there a decided decrease of mor- 
bidity due to nutritive disturbances. Therefore, from the end of the second 
year the nutrition of the child need not differ greatly from that of the adult. 
It is obvious that this period need not be limited to a definite day or month; 
it merely represents an average basis for calculation. 

In the second year of life milk continues to be the most important con- 
stituent of food for children. But to prevent a hypernutrition with this I 
do not permit the child to have more than a liter of milk daily, divided into 
four portions, just as I have proposed for the end of the first year. This pre- 
ventive measure at the same time prohibits an exclusive milk diet. Where 
the latter method is carried out the child must have much larger quantities 
of milk to satisfy hunger and to increase the weight. My observation of chil- 
dren who have been nourished with milk exclusively has shown them to be 
conspicuously pale, with flaccid muscles, to some extent rachitic, and to suf- 
fer from constipation. I, therefore, advise against such a regime. 

When the amount of milk is limited to one liter it is necessary to give 
other food. As the albumin and fat requirements of the child are fulfilled 
by the milk, this addition consists of carbohydrates in the form of vegetables. 
The diet of a child in the second year of life is, therefore, as follows : Five 
meals in twenty-four hours; two meals to be composed of 250 c.c. milk each, 
with the addition of zwieback, a roll, or a similar amount of bread without 
butter, in a quantity sufficient to satisfy the child; two feedings of the same 
quantity of milk without bread 1 , and the fifth meal to consist of meat broth 
with grits, rice, barley, noodles, or the like, and followed by vegetables in 
gradually increasing amounts. This diet may be regarded as very monoto- 
nous. In my experience, however, a normal child of this age does not re- 

1 In the latter half of the second year one of these two meals of milk may be 
omitted . 



136 THE FEEDING OF CHILDREN 

quire variation it' it has not been taught to expect it; for example, if apple 
sauce (of which I do not approve on account of the large amount of sugar 
which it usually contains) is given instead of the vegetable, the child will 
very frequently decline the vegetable. If such an alternative is omitted the 
child will enjoy his daily meal of spinach without thought of variation. 
Numerous other examples might be given. 

I must mention here that infant foods are unnecessary for healthy chil- 
children, nor does zwieback prepared by a manufacturer furnish any better 
results than ordinary rolls. 

In the estimation of the results of nutrition in the second year the in- 
crease of weight, which is so important in the first months of life becomes 
secondary to other factors which predominate toward the end of the first 
year, namely, the normal development of the skeleton and of the muscles, of 
the blood, of the psychic functions, etc. 

Unfortunately the literature which relates to the increase of weight of 
normal children during the second year of life is meager. While we esti- 
mate a weight of 10 kilograms (22 pounds) as the average for the end of the 
first year, it is impossible to give a corresponding figure for the end of the 
second year. We must content ourselves w r ith the knowledge that in the 
second year the increased weight is proportionately less than in the first, and 
that it does not show the same regularity. 

At the end of the second year a child which has remained healthy is able 
to assimilate the food of adults and to develop normally under such a diet. 
If there is to be no mistake later, the amount of milk must be decreased in 
proportion as the child is given other food. It is most advantageous to limit 
the milk to a small quantity at breakfast and to omit it for the remainder of 
the day. In adults it has been determined positively that an exclusive or 
predominant milk diet will not maintain the body permanently, yet in chil- 
dren beyond two years of age milk is very often given in large quantities 
with the idea that they are receiving an extraordinarily nutritious food. 
This view seems incomprehensible, since the majority of physicians, as I 
have stated, are now of the opinion that a child should be given the diet of 
adults after the first year. 

In passing to a mixed diet in the third year the essential change relates 
to the animal albumin requirement, which is provided by meat and eggs in- 
stead of milk. If it is necessary to caution against professional hypernu- 
trition when the diet is exclusively of milk, this necessity becomes all the 
more pronounced when albumin is given in the concentrated form of meat 
and eggs. It has frequently been necessary for me to restrict the adminis- 
tration of meat and eggs to two meals daily, and then only in moderate 
amounts. On the one hand the albumin requirement of the growing child is 
not so great as is usually estimated, and on the other hand, we must remem- 
ber that meat and eggs represent acid foods, and that plenty of vegetables 
and fruit are necessary to supply a sufficient amount of alkali. This last 
view governs nre, in opposition to other physicians, in the exclusion of meat 



THE FEEDING OF CHILDREN 137 

and eggs during the first year of life, since experience has shown that young 
infants are readily injured by acid foods. 

In the nutrition of the healthy child I avoid alcohol. Although it has 
been proven that alcoholic combustion takes place in the infantile organism, 
nevertheless, its use is not justified, because of the resulting deleterious ef- 
fects and of a plentiful supply of other and more combustible nutritive sub- 
stances. 

To enter upon the individual points of diet in the third year appears to 
me to be superfluous, as the same fundamental rules apply to children as to 
adults. I must emphasize only one point: While I regard five meals in 
twenty-four hours as necessary and advantageous during the first two years 
of life, I believe that it is better to diminish the number of meals to three 
after the end of the second year. As a matter of fact three meals a day is 
the custom of many countries, but only with the lapse of time, and by the 
combined action of many physicians, will we be able to overcome the con- 
ventional five meals a day in Germany. Although the habit of numerous 
meals may not be harmful, nevertheless it often causes loss of appetite, capri- 
ciousness, and a tendency to digestive disturbances. 

I must state in conclusion that while I am perfectly aware that the fore- 
going is not the only method by which a normal child may grow and flour- 
ish, it is my duty to advise only such a method as will furnish a most cer- 
tain immunity from disease. It is not my object to bring up children who 
are fat-wonders, but to create in them a healthy color and a vigorous mind 
and body, to insure for them a good appetite and proper sleep, and to aid 
them to resist disease; briefly, to develop healthy children. 



THE MOST COMMON INFECTIONS OFTHEORAL 
MUCOUS MEMBRANE IN CHILDREN 

By A. MONTI, Vienna 

By means of the atmospheric air, the food, and other substances which 
come in contact with the oral mucous membrane of children, for example, 
by the ingestion of food and in cleansing the mouth, quite a number of sap- 
rophytic and pathogenic microorganisms gain entrance by which sucking, 
chewing, etc., may produce an excoriation of the mucous membrane, and, 
together with the food residua, present a suitable culture medium for the 
further development of these bacteria. 

These changes vary in that saprophytic microbes alone, or in. combina- 
tion with pathogenic bacteria, exert their influence. We will, therefore, 
.first discuss those changes of the oral mucous membrane which are due to 
saprophytes, and then pass to a consideration of diseases which are the effect 
of pathogenic bacteria. 



I. CHANGES OF THE ORAL MUCOUS MEMBRANE DUE TO 
SAPROPHYTIC MICROBES 

Miller, in his pioneer investigations, has isolated twenty-eight varieties 
of saprophytic bacteria from the cavity of the mouth. For clinical purposes 
a discussion of the changes, and a description of only the most frequent va- 
rieties which appear *in this region, are sufficient. 

Leptothrix buccalis. — The leptothrix buccalis is the most common micro- 
organism found in the oral cavity of children. 

Microscopic examination of the white coating of the teeth, which has 
been spread in thin layers with distilled water, reveals small or larger clumps 
consisting of minute round bodies, at the borders of which there are many 
thin, curved strands. These round bodies are the so-called matrices of the 
leptothrix buccalis. The strands vary in length and are 0.5 to 0.8/* in 
breadth, curved and tortuous, detached, immotile. 

If a small quantity of this white coating is combined with a drop of 
lactic acid in a solution of potassium iodid, and placed under a l/350th 
magnification, the greater portion of this coating is seen to consist of epithe- 
lial cells, clumps of micrococci and rod- and strand-shaped structures of a 
yellowish or yellow tint. 

138 



CHANGES DUE TO SAPROPHYTIC MICROBES 139 

Bacillus maximus buccalis. — In addition to the variety of lcptothrix 
just mentioned we also find the bacillus maximus buccalis, so designated by 
Miller, which is arranged in strands, or, more frequently, in distinct chains 
or rods, 30 to 150m in length, running parallel or crossing one another, with 
regular contours and usually with equally thickened ends. This bacterium 
stains blue with iodin, but not all the cells give the same reaction. Many 
strands stain uniformly, others show areas of brownish violet color. 

Iodococcus buccalis. — Another variety appearing in the cavity of the 
mouth has been designated iodococcus buccalis (Miller). This microorganism 
appears in chains of 4 to 10 cells. These chains have a sheath wherein the 
cells are shaped like flat discs or four-sided bodies, sometimes with rounded 
corners. The sheaths do not stain with iodin or at most they present a faint 
yellow color under prolonged exprosure; the cells, however, are always 
stained deep blue or violet. 

The fungi above-mentioned adhere also to the tongue, particularly to the 
filiform papillae and in the grooves between them. 

Their culture media are desquamated epithelium and decomposed remains 
of food. 

Mould Fungi. — In addition to leptothrix other saprophytic microbes, 
such as the numerous varieties of mould fungi, may be found in the mouth. 

The most common are small-celled sarcinae, which rapidly multiply in 
the oral cavity, and also appear upon the uvula, the palatine arch, etc., as a 
whitish area resembling thrush. They are found loose in small clumps 
between the epithelia of the tongue, of the mouth, and of the pharynx, or 
are arranged in clusters at the border of the epithelium. They may even 
form a coating. 

It is certain that the saliva has an antiseptic effect upon these saprophytes, 
and with a sufficient normal secretion these bacteria are not capable of pro- 
ducing essential disturbances in the mouth. But in children under two years 
of age, in whom the production and composition of the saliva is not yet 
completely developed, or in individuals in whom the salivary secretion has 
undergone a pathologic change due to general nutritive distubances, these 
saprophytes may give rise to the well known local and chemical changes in 
the oral cavity which are designated " catarrhal stomatitis." 

Catarrhal Stomatitis. — Because of the deficient function of the salivary 
glands in the new-born, catarrhal stomatitis is an almost constant lesion 
during the first days of life. A more or less conspicuous redness develops 
in the mucous membrane of the mouth, which leads to a partial desquama- 
tion of the epithelium. 

The oral catarrh of the new-born reaches its acme in four to six days, 
according to the action of the saprophytes, and as a rule disappears gradually 
in the course of eight to fourteen days; with improper care of the mouth, 
however, it may continue longer. Where the mucous membrane is tense, 
especially on the palate and on the tongue, large areas of epithelium may 
desquamate, leaving excoriations and small extravasations of blood. 



140 COMMON INFECTIONS OF THE ORAL MUCOUS MEMBRANE 

In catarrhal stomatitis of the new-born the child sucks painfully and 
with difficulty, and as a consequence less nourishment is taken. This dimin- 
ished feeding may readily lessen the secretion of breast-milk and the contact 
of the oral secretion — which contains the saprophytes — with the delicate 
nipples produces reddening, irritation, and excoriation. 

Catarrhal stomatitis usually results in recovery without special treatment. 

If, however, pathogenic bacteria gain entrance to the mucous membrane 
during the course of this malady, they find a suitable soil for the production 
of pathologic changes, which will be described later. 

In nurslings and older children these saprophytes cause local changes, 
especially if the function of the oral mucous membrane has undergone dam- 
age from insufficient care of the mouth, from intercurrent febrile affections, 
or from inflammatory processes of neighboring organs, whereby a favorable 
culture medium is offered for the microbes. The phenomena are the same 
as in the new-born: redness, swelling, desquamating epithelium, and sapro- 
phytes which may be demonstrated microscopically. 

By means of, or even without, this local action, and whether or not the 
oral cavity is cleansed, these saprophytic bacteria may produce acid fermen- 
tation in the food residua in the mouth : lactic acid-, butyric acid- or acetic 
acid-fermentation. Notwithstanding the normal appearance of the mucous 
membrane, children exude an offensive acid odor from the mouth, particu- 
larly when the tongue is slightly coated, and the reaction of the secretion 
in this region is acid. This odor is particularly noticeable in the morning 
and is very often explained incorrectly. In consequence of this fermentative 
process the child shows a certain aversion to food and the cause is erroneously 
referred to as gastric catarrh. Upon close examination of such cases, however, 
we find a normal function of the stomach, and proper disinfection of the oral 
cavity soon disperses the trouble. 

In addition, these saprophytic bacteria may exert a diastatic action upon 
the carbohydrates of the food. The children then complain of a sweet taste, 
reject certain foods, or take very little nourishment, although the digestive 
organs may be intact. 

Usually these bacteria have a decomposing action upon the albumin sub- 
stances and fats in the remains of food in the oral cavity which changes 
them first into peptones and finally produces putrefaction. These patients 
often emit such a strong putrid odor from the mouth that even strangers 
note it. In this condition the tongue is furred and there is a thin white coat- 
ing upon the gum. These symptoms are very often incorrectly referred to 
digestive disturbances. 

Here also a proper disinfection of the oral cavity rapidly relieves the 
trouble. 

So long as the foregoing changes are not extensive the symptoms are 
local; if, however, the lesions become marked by the action of these sapro- 
phytes, as may easily occur with improper care of the mouth, they may lead 
to infection of other organs: to infection of adjacent areas if the teeth are 



INFECTIONS DUE TO PATHOGENIC BACTERIA 141 

carious, to disease of the respiratory passages (putrid bronchitis, etc.) by 
the inspiration of putrefactive bacteria, to infection of the digestive organs 
by deglutition of the bacteria of fermentation and their toxins. Large quan- 
tities of gas may accumulate which give rise to various disturbances. Such 
a large quantity of alkaline products may be formed by decomposition of 
proteid substances that when they reach the stomach there may be a neutrali- 
zation of the hydrochloric acid. Absorption of the toxins may also cause 
disease. 

However, our knowledge of these sources of infection at present is so 
slight that an accurate description is impossible. We must limit ourselves 
in this article to a consideration of the control of the saprophytes, and insist 
upon thorough cleanliness of the mouth in all children. 

II. INFECTIONS DUE TO PATHOGENIC BACTERIA 

When pathogenic bacteria gain entrance to an altered or excoriated 
mucous membrane, brought about by the action of saprophytes, they usually 
produce pathologic changes, whereas they are without effect upon the normal 
mucous membrane. 

Oidium albicans (Thrush; sprue; muguet; soor). — In the new-born the 
oidium albicans often causes a peculiar infection of the mucous membrane. 
The germs of thrush commonly find their way from without to the oral 
mucosa by means of the inspired air, or by adherence to substances which 
come into contact with the oral mucous membrane of the child (the nipple, 
substances with which the mouth is cleansed, in artificially-fed children the 
rubber nipple, etc.). It is also believed that the oidium albicans collects 
and multiplies upon acid — fermentating residua of food — substances con- 
taining sugar and starch — and are thus introduced with the nutriment. 

These spores may be present in the secretion of the oral mucous mem- 
brane even in healthy children, but here they do not find a suitable soil and 
are harmless. 

The oidium albicans adheres and proliferates only upon a mucous mem- 
brane which is irritated and excoriated; it then forms disseminated, ring- 
shaped, punctiform white deposits, preferably upon the papillae of the tongue, 
from whence it attacks the mucous membrane of the cheek and of the palate, 
and may implicate the entire mucosa of the mouth. 

Microscopic examination of these punctiform deposits reveals numerous 
strands and spores of the oidium albicans, and in addition various mould 
fungi, epithelium, etc. 

These deposits rapidly multiply and enlarge, and when the disease is 
further advanced they form a white membrane-like covering of the mucous 
membrane which is especially marked upon the tongue. If the formation 
is extensive, similar coatings may appear on the lips, cheek, palate, and the 
gums, so that the entire oral cavity may seem to be covered by layers of the 
oidium albicans. 



142 COMMON INFECTIONS OF THE ORAL MUCOUS MEMBRANE 

This bacterium is firmly adherent to its foundation and in well-marked 
cases presents a dirty white, tenacious, crust-like mass. The underlying 
mucous membrane is reddened, loose, and bleeds readily; the papillae of the 
tongue are red and here and there have lost their epithelium. Those areas 
of the mucous membrane which are free of the oidium albicans often appear 
to be in a state of inflammatory irritation. When the disease is prolonged this 
inflammatory reddening of the mucous membrane and swelling of the papillae 
of the tongue decrease and the epithelium presents a glistening appearance. 

The oidium albicans occasionally develops also upon the posterior wall 
of the pharynx, where it forms small, firmly adherent points; it may even 
find its way into the esophagus, although here it never reaches a great 
intensity. 

Clumps of the oidium albicans may sometimes be found in the gastric 
juice, but firmly adherent vegetations upon the gastric mucous membrane 
have not been demonstrated. According to Grawitz the yeast organisms found 
in the gastric juice of children suffering from the effects of the oidium 
albicans are only peculiar gonidial forms of this parasitic fungi which develop 
into long strands in the acid gastric juice. The formation of such gonidia 
in the stomach causes a functional disturbance, such as dyspepsia which is 
a frequent accompaniment of thrush. The passage of these gonidia through 
the intestine with the dejecta may, on account of the increased acidity of the 
feces, produce an irritation of the skin surrounding the anus, and it is certain 
that the erythema and eczema in this region, so frequently observed in chil- 
dren who are affected by thrush, owe their origin to this circumstance. 

The distribution of thrush to the nose and larynx has been much ques- 
tioned, and is undoubtedly a rare occurrence. 

Some authors believe that the oidium albicans is capable of entering the 
vessels and causing metastasis;, for example, Zenker mentions thrush metas- 
tasis in the brain, Brindeau in the parotid gland with abscess formation. 

The symptoms produced by the oidium albicans vary according to the 
distribution. Small islands upon the tongue and upon the mucous mem- 
brane of the cheek cause but little inconvenience. With a greater dissemina- 
tion sucking becomes difficult and painful, the child cries, and there may 
even be a rise of temperature, loss of sleep with accompanying unrest, and 
digestive disturbance — dyspepsia, intestinal catarrh; when the soft palate 
and the posterior pharyngeal wall are attacked, deglutition is difficult. If 
the disease is prolonged the growth of the child is retarded, and on account 
of the insufficient ingestion of food there is rapid emaciation, loss of sleep, 
and pain. Under such circumstances there may be a fatal termination, 
naturally not as a direct consequence of the thrush affection, but as the 
result of complications, such as acute gastric and intestinal catarrh, etc. In 
those rare cases wherein the larynx is implicated there may be hoarseness, 
cough, croupy respiration, and attacks of suffocation. 

In children who are debilitated or who have insufficient attention relapses 
are quite possible. 



INFECTIONS DUE TO PATHOGENIC BACTERIA 143 

Diagnosis. — Diagnosis with the aid of the microscope is easy. In the 
white coating will be found a dense mass of strands, round cells, epithelium, 
mucus, corpuscles, micrococci and milk globules, and, if detachment is diffi- 
cult, blood-corpuscles may also be apparent in the microscopic specimen. 

The thrush strands have a double contour, are transparent and colorless, 
either unbroken and solid, or elongated, separated from one another by 
sheaths of colorless or pale yellow links in which occasionally small round 
cavities may be distinguished. The individual strands also show thready 
processes (gonidia), which form an irregular net- work. At the end of the 
thread we occasionally see a clubbed swelling, the so-called spores; these are 
round, quite large, strongly refractive, pale or pale yellow, and are isolated, 
or united in irregular clumps of two, three, or more. 

If the affection is prolonged the thrush masses consist for the most part 
of spores, which contain numerous microorganisms, but few or no strands. 

The histologic examination of the oral mucous membrane which is covered 
by the parasite reveals that these have layered themselves upon the epithelial 
coating, and that they collect principally in the grooves between the papillae. 
Isolated mycelial strands and spores may penetrate more deeply between the 
epithelial cells. 

The diagnosis may also be made by culture methods. The parasite grows 
best in feebly acid or sugar-containing gelatin, and upon potatoes. By 
repeated inoculation pure cultures may be obtained. 

These measures easily determine the diagnosis of thrush and error would 
seem impossible. As the microscopic examination, and even the culture 
process, can readily be carried out by any educated physician, a discussion 
of the differential diagnosis from other diseases of the oral mucous membrane 
will be omitted. 

Prognosis. — In healthy children the disease is readily amenable to treat- 
ment, notwithstanding its intensity and distribution, particularly if the child 
is nourished with breast-milk and is protected by favorable hygienic sur- 
roundings. Only in debilitated children, nourished artificially with various 
infant foods, condensed milk, etc., who are suffering from gastric or intestinal 
disease, is the affection likely to be severe. In such cases the prognosis 
depends upon the nutrition of the child, the severity of the underlying gastro- 
intestinal affection, and the duration of the disease. 

Stomatitis gonorrhoica. — Another infection of the oral mucous mem- 
brane by pathogenic bacteria has recently been recognized, — that due to 
gonococci. 

In rare instances the oral cavity of the child at birth is infected by the 
transmission of gonorrheal secretion from the vagina and vulva of the mother, 
whereby a peculiar form of stomatitis arises which has been designated stoma- 
titis gonorrhoica. 

In this infection the entire oral mucous membrane is reddened, swollen, 
permeated at individual points by pus. Gonococci may be demonstrated and 
cultivated from the secretion of the mucous membrane. 



144 COMMON INFECTIONS OF THE ORAL MUCOUS MEMBRANE 

This form of stomatitis usually develops slowly and becomes noticeable 
only after the fourth day from birth. 

The staphylococci and streptococci which are simultaneously present in 
the secretions of the vulva produce an extraordinarily painful and stubborn 
purulent infiltration of the soft palate and of the tongue. 

Severe catarrhal stomatitis in the new-born, running its course with 
purulent infiltration, should awaken the suspicion of gonococcus infection, 
and this condition should receive primary consideration. 

Staphylococci and Streptococci. — A more frequent infection of the mucous 
membrane of the mouth is by staphylococci and streptococci. 

The transmission of these organisms to the mucous membrane of a healthy 
child is usually without effect, but if the mucosa is inflamed as a result of 
mechanical injury or the action of saprophytes, these microorganisms find a 
suitable soil for infection which runs a peculiar course. 

Redness and swelling of the oral mucous membrane suddenly develop, 
particularly at those points at which there has been previous damage; in 
consequence sucking is difficult and the child becomes very restless. 

According to the condition of the mucosa prior to infection the lesions 
occur variously on the lips, the tongue, the soft palate, etc. The soft palate 
in particular is often affected, while the mucous membrane of the hard palate 
remains normal, — a coincidence which is explained by the fact that the epi- 
thelium of the soft palate is often scratched by unskillful cleansing of the 
mouth. 

This affection is usually combined with a rise in temperature, seldom 
greater than 39°-40° C. (102.2° to 104° F.) which is more or less elevated 
according to the distribution of the process. 

Twenty-four to forty-eight hours after infection the implicated areas of 
the mucous membrane are infiltrated and show a purulent covering; in the 
new-born this condition is most common on the soft palate and palatine 
arch; occasionally the lips, the tongue, the hard palate and the posterior 
pharyngeal wall are infected. In severe cases the entire oral mucosa may 
be implicated. 

Microscopic examination reveals staphylococci and streptococci, which are 
readily susceptible to cultivation. 

The course of the infection is as follows: After a few days the purulent 
infiltration reaches its acme; the mucous membrane becomes pale, the febrile 
phenomena are less intense, the purulent infiltration desquamates and the 
excoriated areas cicatrize. This process advances slowly and may last several 
days or even weeks. 

In severe cases the infection may involve the underlying structures and 
thus deep ulcerations may arise in different areas of the mucosa, most fre- 
quently upon the borders of the jaw, the lips, the frenum of the tongue, and 
even upon the hard or the soft palate. When such a condition is present 
there is usually an evening febrile exacerbation, the child becomes restless, 
and nursing is difficult. If cicatrization is delayed the child is debilitated 



INFECTIONS DUE TO PATHOGENIC BACTERIA 145 

and an infection of the gastric and intestinal mucosa, septic intestinal disease, 
or the symptoms of general sepsis may appear. The purulent infiltration of 
the mucous membrane by the entrance of cocci leads to more or less swelling 
of the adjacent lymph glands. The skin may become infected from the flow 
of saliva and result in phlegmonous inflammations upon the neck, the 
face, etc. 

This infection of the oral mucous membrane is sometimes complicated 
with thrush. 

Prognosis. — The prognosis is dependent upon the intensity and extent of 
the process. With widely distributed ulceration the disease is tenacious. There 
may be septic infection of the neighboring organs, of the nose or the intes- 
tines, or of the entire mucous membrane, and there may be a lethal outcome 
due to general sepsis. 

Stomatitis aphthosa. — Staphylococci may lead to a typical infection of the 
oral mucous membrane which has been designated stomatitis aphthosa, wherein 
a coagulated mass is deposited in the upper layers of the mucosa. 

This affection is observed in children before and following dentition; it 
is rare before this period, is frequent during teething, and reaches its acme 
between the first and third years of life. 

In the intact mucous membrane the staplrylococci are inactive ; but if 
the mucosa has been damaged by accumulation of saprophytes or has been 
irritated by food or by chemical or mechanical means, the microbes find a 
suitable . point of attack. It is assumed that the ingestion of certain foods 
and drinks, such as sharp cheese, fruits in process of fermentation, pungent 
spices, very cold or hot fluids, and mineral or organic acids, may damage 
the epithelial layer of the oral organs to such an extent as to permit infec- 
tion by staphylococci. It has also been maintained that the ingestion of milk 
obtained from animals infected by foot-and-mouth disease is capable of pro- 
ducing a similar affection. 

Aphthous stomatitis may be the sequel of other infectious diseases, pro- 
vided saprophytes have prepared a soil suitable for its development. 

That stomatitis aphthosa is an infection due to staphylococci is demon- 
strated by the clinical phenomena, such as typical fever, implication of the 
lymph glands, and the contagiousness of the disease. 

From the foregoing it is obvious that two factors are necessary for the 
development of aphthous stomatitis: 1. A disease of the oral mucous mem- 
brane which runs its course with increased secretion and with an elevation 
of temperature; 2. that staphylococci find their way to this altered mucosa, 
which may then be demonstrated as the pathogenic agent. 

In consequence of staphylococcus infection, isolated inflammatory areas 
of small and usually rounded contour appear upon the mucous membrane, 
with redness and swelling of the surrounding epithelium. In the further 
course the inflammation is distributed over the entire mucosa, so that the 
lips, the gums and cheeks, the soft and hard palate, and the tongue are 
intensely red and swollen. 
11 



146 COMMON INFECTIONS OF THE ORAL MUCOUS MEMBRANE 

In the next day or two an exudate is formed under the epithelium in the 
areas originally reddened and inflamed, which, at various places upon the 
oral mucosa, produces firmly adherent flakes which are round or elongated 
and of a pale color in the thin layers or of a yellowish tint where they are 
thicker. Closer examination with the aid of the microscope reveals an 
amorphous mass composed of epithelial cells, fibrin in small granules, more 
or less numerous young cells, but principally of cocci. The saliva shows an 
increase of epithelial cells and numerous leukocytes. 

The affection reaches its acme in two or three days. The mucous mem- 
brane then begins to fade; the exudate is gradually surrounded by a red 
areola which becomes quite distinct, and by resorption the superficial layers 
decrease in size and finally disappear under the formation of new epithelium. 

If the exudation is profuse the epithelium is raised and may be desqua- 
mated. Even in such areas only a white speck remains, which in time 
disappears. 

Aphthous stomatitis never leaves cicatrices. 

The disease runs its course with fever. Simultaneously with the redness 
and swelling there is a rise of temperature in mild cases to 38° C. (101° F.), 
and in severe affections it may reach 40° C. (104° F.). 

After exudation is completed, which occurs in two or three days, the 
temperature falls and during resorption and elimination of the exudate there 
are at most slight evening exacerbations. Only with renewed exudation is 
there a recurrence of fever. 

It will therefore be readily observed that aphthous stomatitis usually runs 
the following course: First, disseminated or cumulated redness and swelling 
appear on different portions of the oral mucous membrane with salivation 
and fever. Later the inflammation distributes itself to the entire mucosa 
of the mouth. The child refuses food because of pain; mastication is espe- 
cially troublesome and may cause hemorrhage of the mucous membrane. As 
the result of pain and of fever the child becomes restless, sleepless, and cries. 

In the two succeeding days a profuse grayish-white exudate is formed 
upon the originally reddened areas, with enlargement of the submaxillary 
glands. By confluence of this exudate larger areas may reveal the same 
appearance; such a condition is especially common at the tip of the tongue. 

The subsequent course depends upon the intensity of the infection. If 
the process is limited to the tongue, the cheeks and the lips, in three or four 
days the redness and swelling of the mucous membrane and the salivation 
decrease, and the exudates disappear in the same sequence in which they 
developed. At the same time there is amelioration of the functional dis- 
turbance and the child again takes food. 

In rare instances the exudate may be deposited upon the epiglottis and 
at the entrance to the larynx, whereby edema appears in this region and 
presents laryngo-stenotic phenomena which resemble the clinical picture of 
laryngitis. 

Stomatitis aphthosa usually heals in eight or ten days. When relapses 



INFECTIONS DUE TO PATHOGENIC BACTERIA 147 

occur from renewed infection the disease may continue for several weeks, 
and the disturbances resulting therefrom, such as the insufficient ingestion 
of food, give rise to marked emaciation. 

Bednar's Aphthae. — Another local infection of the oral mucous membrane, 
due to cocci, is produced by Bednar's aphthce, which are most prevalent in 
nurslings. 

These form symmetrically round or elongated losses of substance upon 
the palate at the point where the mucous membrane covers the hamulus ptery- 
goideus. This constant seat and the symmetric appearance of the ulcers 
appear to be favored by peculiar anatomic and physiologic conditions which 
dominate this area of the oral cavity. The mucous membrane of the mouth 
is exposed to a constant muscle-tugging produced by the movements of 
the jaws and also by the strong compression of the tongue against the hard 
palate. 

Immediately following birth the hyperemia, previously described, appears 
upon the oral mucosa, which usually becomes irritated in consequence of 
the aforesaid influence exerted upon the palate. Constant pressure loosens 
the epithelium and causes desquamation, whereby lesions and ulcers appear. 
These excoriations form a suitable culture media for the cocci which find 
their way into the oral cavity, and a purulent infiltration of the mucous 
membrane arises in these areas. This condition may be induced by staphy- 
lococci as well as by streptococci, and, according to some authors, even by 
gonococci. 

Corresponding to this conception of the causative factors Bednar's aphthae 
commonly develop during the first week of life, and often twenty-four hours 
after birth; only exceptionally are they observed in older infants. 

These aphthae are usually superficial. By destruction of tissue they may 
invade deeply and form ulcers with sharp borders and a gray-coated base. 
As a rule, however, the ulceration remains shallow, but may extend from its 
inner border and thereby form a raw surface which distributes itself over 
the soft palate. By this process both aphthae may appear to be connected 
by the purulently infiltrated mucosa. 

Microscopic investigation shows that Bednar's aphthae consist of necrotic 
elements, epithelium, pus-corpuscles, lymphoid cells, numerous cocci in the 
necrotic tissue, which permeate into the dilated vessels of the mucous mem- 
brane. 

In a few days the gray mass which covers the base of the ulcer desqua- 
mates, the loss of substance is offset by the formation of granulations, and, 
with the formation of the epithelial covering, healing is complete. 

This growth of epithelium begins at the border and healing takes place 
without cicatrization. 

If the affection has distributed itself over wide areas of the mucous mem- 
brane the disease is prolonged and recovery by the formation of new epithelium 
is delayed. This is especially the case when there has been deep invasion 
of the tissues. 



148 COMMON INFECTIONS OF THE ORAL MUCOUS MEMBRANE 

A common complication of Bednar's aphthae is the oidium albicans, which 
greatly retards recovery. 

In well-nourished children, and with proper care, Bednar's aphthae heal 
rapidly. In debilitated children who are artificially nourished the affection 
may be very tenacious. The prognosis is generally much more favorable 
in children fed with breast-milk than in those who are otherwise nourished. 



III. BACTERIA OF DECOMPOSITION 

The development of putrefactive bacteria in the decomposed remains of 
food which accumulate upon the gingiva, upon the teeth and between them, 
gives rise to an especially characteristic inflammation of the tissues which 
changes them into a pulpy mass and terminates in necrosis. In this affection 
Friihwald discovered a bacillus which grows upon gelatin and disseminates 
an odor of decomposition. In my opinion this process is the effect of various 
forms of putrefactive bacteria. 

Stomatitis ulcerosa. — The regularity with which the process leads to 
necrosis of the gum, its tendency to invade deeply, its transmission to neigh- 
boring areas of the oral mucous membrane, the circumstance that ulcerative 
stomatitis occurs only in children who already have teeth and most frequently 
between the fourth and tenth years, and that the affection is rare from the 
first to the third year when greater attention is bestowed on the care of the 
mouth, are indirect proofs of the action of putrefactive bacteria as causal 
factors. As a further support for this view, the disease in question is most 
frequently noted in children with carious teeth or in the course of, or during 
convalescence from, severe infectious disease. 

It is supposed that decomposed particles of food which are retained on 
the gums and between the teeth produce irritation and inflammation in these 
areas and that this condition occurs most readily and rapidly in anemic chil- 
dren. These swollen and inflamed regions are frequently squeezed and injured 
in chewing so that the putrefactive bacteria which are present have ready 
access to the tissue and cause necrobiosis. Present experience indicates that 
several varieties of the bacteria of decomposition are present simultaneously. 

Symptoms. — The symptoms of ulcerative stomatitis are as follows : 

The gum, either in a circumscribed area or over the entire jaw — in well- 
marked cases upon both jaws — becomes dark red and loosened. The lower 
margin is swollen and bleeds readily upon contact; simultaneously a putrid 
odor is diffused from the mouth; salivation is increased and other areas of 
the oral mucosa are also reddened. 

As the disease progresses the external free border of the inflamed gum 
alters its color and becomes a yellowish mass; if this is brushed with cotton 
the mucous membrane beneath appears livid, bleeds readily and has an ex- 
coriated appearance. 

Necrosis of the gum thus begun usually distributes itself downward and 



PROPHYLAXIS AND TREATMENT 149 

may change the entire area into a necrosed mass. The space between the 
teeth and the posterior surface may be implicated by this decay, so that in 
severe affections the teeth are entirely denuded of gum. 

During this process usually there is enlargement of the submaxillary 
glands. 

When the necrotic process of the gum is fully developed, those portions 
of the oral mucosa which come in contact with the necrosed parts when the 
jaws are closed (lower and upper lips, cheeks, margin of the tongue) are impli- 
cated in a like manner. These areas form inflammatory foci which, in their 
course, become grayish yellow, and, after desquamation of the epithelium, 
are changed into a necrosed mass which exudes an exceedingly fetid odor. 
After these masses are expelled there are irregular losses of substance with 
a grayish yellow base surrounded by a swollen mucous membrane with serous 
infiltration. 

The malady usually terminates in recovery. The offensive odor of the 
mouth disappears with the desquamation of the necrosed tissue, salivation 
decreases and the loss of substance is gradually replaced by granulation. 

Noma may result from the deep invasion of the process in the cheek; if 
the periosteum is implicated there may be partial necrosis of the jaw. 

The course of the disease is either acute or chronic. 

When the process lasts for a long time the nutrition of the body suffers 
and death may occur from general sepsis. 

The diagnosis is dependent upon a careful microscopic examination of the 
products of the disease and upon the sequence and nature of the symptoms. 
By a strict utilization of the points of support which have been mentioned 
a confusion of this affection with any other disease of the mouth is hardly 
possible. 

In well-nourished children the prognosis is favorable. In debilitated 
patients and after a prolongation of the disease the termination may be fatal. 

PROPHYLAXIS AND TREATMENT 

To prevent the development of the above-mentioned infections of the oral 
mucosa in children it is necessary for the physician to give attention to the 
cleansing and disinfection of the oral cavity. 

Prophylactic antisepsis is governed by the age of the child, the condition 
of the mucous membrane, and the nature of the threatening infection. 

Above all, routine washings and improper treatment of the oral mucous 
membrane, so commonly practised by uneducated nurses, must be prevented. 
All articles by which the child is fed (spoons, glasses, rubber nipples, etc.) 
are to be sterilized before use. In breast-fed children the nipple should be 
bathed before and after nursing with a one per cent, boracic acid solution. 

Infection by saprophytes may be prevented by cleansing the oral mucosa 
of the new-born once or twice daily with sterilized water. This may be best 
accomplished with a cotton tampon. 



150 COMMON INFECTIONS OF THE ORAL MUCOUS MEMBRANE 

When older children retain food in the mouth because of the large quantity 
ingested, or as the result of insufficient mastication and improper deglutition, 
a careful washing of the mouth after each meal with distilled water to which 
some aqua menthae or lemon juice has been added is serviceable. 

For the prevention of catarrhal stomatitis or chemical decomposition, due 
to saprophytes, the following is a useful antiseptic mouth wash : 

R/. 

Acid, bor 3.0 

Aq. font, dest 200.0 

Tinct. myrrh 2.0 

M. Sig. : Rinse the mouth three times daily. 

The teeth must be cleansed thoroughly to keep them in good condition 
and to prevent fermentative processes and decomposition. For this purpose 
the following tooth powder may be employed: 

E/. 

Magnes. carbon 5.0 

Cret. alb. praep. 

Natr. salicyl aa 15.0 

01. menth. pip gtt. vi 

M. Sig. : Tooth powder. 

When a fetid odor emanates from the mouth in consequence of fermenta- 
tion and putrefaction the following solution is of value for cleansing the 
oral mucous membrane: 

R/. 

Natr. salicyl. 

Natr. phosphor aa 2.0 

Aq. font, dest 300.0 

01. menth. pip gtts. v 

M. Sig. : Mouth wash. 

Infection of the oral mucosa by pathogenic bacteria requires special thera- 
peutic treatment in addition to the foregoing methods. 

In infection by the oidium albicans all food-stuffs which appear to favor 
the development of this parasite, such as sugars and syrups, should be avoided. 

As this bacterium is present in the air, thorough ventilation of the bed- 
room is to be urgently advised, particularly in institutions. 

The mechanical removal of the deposits of oidium albicans without injury 
to the epithelial layer is indicated. The mouth should be washed with a 
cotton tampon which has been dipped in a 2 per cent, solution of boracic acid 
or sodium borate. A fresh tampon should be employed for each portion of 
the oral cavity, and every fold and niche must be carefully cleansed. A 5 
to 10 per cent, solution of sodium borate or a 3 per cent, solution of sodium 



PROPHYLAXIS AND TREATMENT 151 

benzoate is very serviceable for this purpose. Some authors advise solutions 
of potassium permanganate, resorcin, and even corrosive sublimate. Care- 
less employment of these remedies is dangerous and I therefore do not advise 
them. 

Prior to each of these manipulations in the mouth the nurse must care- 
fully disinfect her hands with soap. 

When gonococci are present in the oral mucosa I employ 

B/. 

Alum, crud 0.5 

Acid, carbol 0.2 

Aq. font, dest 200.0 

The mouth should be cleansed with cotton tampons, as in infection by 
oidium albicans. 

In staphylococcus and streptococcus infection tannin may be used as a 
dusting powder, or washes of a 2 per cent, solution of tannin ; in severe cases 
iodoform or sozoiodol may be employed. 

As this infectious disease is very painful lukewarm food only is advised. 

To prevent deglutition of the cocci, the oral cavity should be cleansed 
before each meal with a 2 per cent, boracic acid solution. 

In this infection the avoidance of certain articles of diet, such as pap, 
infant foods and milk sugar, is essential. In severe processes the mother's 
milk is the best food ; where this cannot be obtained I employ a mixture of 
milk and whey, which I call infant milk. 

Ventilation of the room and scrupulous cleanliness (removal of dirty 
bath water, soiled sponges, etc.) are of the utmost importance for the pre- 
vention of renewed infection. 

In aphthous stomatitis the same general antiseptic rules apply, and, in 
addition, the mouth should be cleansed several times daily with antiseptic 
fluids (boracic acid, tannic acid). 

Because of the pain only cool fluid nourishment should be administered, 
and the mouth should be frequently rinsed with cold water. 

The following mixture may also be employed: 

B/. 

Kal. chlorat 3.0 

Aq. font, dest 200.0 

Tinct. myrrh 3.0 

When pain is intense and there is confluence of the aphthae I advise the 
employment of corrosive sublimate solution : 

B/. 

Hydrarg. chlor. corros 0.1 

Aq. font, dest 100.0 



152 COMMON INFECTIONS OF THE ORAL MUCOUS MEMBRANE 

Some physicians employ potassium permanganate, tannoglycerin 1 to 30, 
or cocain, similar to the following : 

E/. 

Natr. salicyl 0.1 

Cocain. hydrochlor 0.2 

Aq. font, dest 10.0 

M. Sig : Cautiously applied in the mouth. 

Bednar's aphthae are to be treated likewise. The deep ulcerations should 
be dusted with iodoform or sozoiodol. 

In ulcerative stomatitis the following measures are to be employed : Some 
cotton is swabbed around the tooth and the necrosed areas of the gum are 
thus removed, the bleeding borders being treated with a 2 per cent, solution 
of carbolic acid. If necrosis has not yet developed, frequent washing with 
the following solution is of service: 

B/. 

Kal. chlor : 3.0 

Tinct. ratanh 5.0 

Aq. font. dest. . . .* 200.0 

When the necrosis permeates deeply, careful dusting with iodoform is 
to be employed to prevent infection of the neighboring areas, and if the 
mucous membrane of the cheek is invaded the Paquelin cautery must be 
applied to prevent the development of noma. 

[Frequent contact of the chlorate of potassium or of sodium is advisable 
in most of the forms of stomatitis, mainly the ulcerous. At the age of 1 or 2 
years one gram — 15 grains daily is tolerated without injury. That may be 
dissolved in 150 c. c. — 5 ounces of distilled water, of which y 2 teaspoonful 
may be swallowed every 15 minutes while the baby is awake. Thus there is a 
constant local contact, beside the general effect. — Editor.] 



ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

By TH. ESCHERICH, Graz 

HISTORY 

Because of their frequency and danger the digestive disturbances of infancy 
have long occupied the attention of physicians, even before the establishment 
of pediatrics as a substantive science. In the works of Aretaeus, Abercrom- 
bie, van Swieten, and others, detailed descriptions have been devoted to these 
diseases. A more intimate understanding of their peculiarities, however, 
developed simultaneously with the special investigation of diseases of infancy, 
and one of the principal factors which brought pediatrics into prominence 
was the devastation which gastro-intestinal affections had wrought among 
infants, especially in foundling institutions. 

The first fundamental results in this science were achieved at the begin- 
ning of the nineteenth century, in the illustrious period of French medicine 
to which we are indebted for the foundation of modern diagnosis. Under 
the mighty influence of Broussais's idea the first rational treatises of the 
pathologico-anatomical conceptions and findings were published by Denis 
(1826) and Billard (1828), and were soon followed by those of Louis (1829), 
Valleix (1838), Barrier (1841), Legendre (1846), Hervieux, and others. 
The active interest which was devoted to this subject by the whole science of 
medicine is evinced by the participation of Trousseau and Cruveilhier in the 
elaboration of many of the important problems of pediatrics. 

German pediatrics, which was still involved in nature philosophy, and 
was directed into wrong paths by the incorrect teachings of Jager regarding 
gastromalacia, has as yet nothing equally brilliant to offset this. Only during 
the 50s of that century did new and substantive methods enter into the realm of 
gastro-intestinal affections, and these were introduced by the Austrian school 
in the foundling asylums of Vienna and Prague. To this period belong the 
labors of Bednar (1850), v. Ritter, Steiner, Lambl, and Mayr, and the culmi- 
nation was reached in the comprehensive description of Widerhofer (1880) 
in Gerhardt's Handbook of Diseases of Children. The pathologic types which 
arise in infancy, the semeiotic and the pathologico-anatomical changes, in so 
far as they could be recognized macroscopically, were so exhaustively described 
that up to the present time nothing essentially new has been added. On the 
other hand, our knowledge of the etiology and pathogenesis of these affec- 
tions, which alone would permit an insight of their nature, was still exceed- 

153 



154 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

ingly scant, and no means could be discovered to illumine this obscure realm 
other than by pure clinical observation. 

Meanwhile in German}', a method rapidly developed from modest begin- 
nings — the study of physiology and artificial nutrition and the problems con- 
nected therewith — which gave promise of a more hopeful result. A brief 
description will be devoted to this last aspect, which still holds our attention. 

First, we will consider the investigations of Biedert regarding the differ- 
ence between breast milk and cow's milk, and the conclusions he deduced 
therefrom which unfolded the scientific theories of artificial nutrition. The 
fundamental idea in this was the injuriousness of casein, which, according to 
the knowledge then extant, represented the principal difference of cow's milk 
in comparison with human milk. It therefore followed that this was the 
cause of the surprisingly high morbidity and mortality of artificially fed 
infants — a view which was confirmed early in the fourth decade of the last 
century by the investigations of Eau, Lichtenstedt, and others. 

Bacteriology, which was founded by Pasteur and Koch, revealed the 
presence of numerous small living organisms in cow's milk, which established 
a further important difference. Similarly as in surgery, here also a practical 
achievement, the invention of the Soxhlet apparatus, smoothed the way for 
scientific theories. At the Congress of Natural Philosophers at Wiesbaden 
in 1887 the view was first promulgated that bacteria are the most frequent 
and most dangerous generators of digestive disturbances. To-day this view 
is general, not only in regard to the digestive system but in every region 
of pathology, and only as to whether bacteria produce disease by direct 
invasion of the intestinal wall, or indirectly by decomposition of the deleteri- 
ous residue of food, are there differences of opinion. 

In addition to the above-mentioned variations in the results of artificial 
and natural nourishment, we have the following objective facts upon which 
the bacteriologic hypothesis is based: 1. The increase in the frequency and 
severity of diseases during the hot season, especially in artificially fed chil- 
dren — first noted by American authors (Dewees, 1833). According to Bagin- 
sky (1875) the only explanation of this increase is that under the influence 
of the higher temperature, which favors bacteriologic decomposition, deleteri- 
ous agents are propagated which produce disease in the infantile organism. 
2. The occurrence of epidemic cholera infantum, as was first noted in breast- 
fed children in foundling asylums, and later in those artificially nourished 
in the infant department of the Berlin and Graz Children's Clinic. 3. The 
character of the evacuations, which, in the healthy child, contain a uniform 
flora of few varieties, while in intestinal diseases additional bacteria, particu- 
larly those of a pathogenic nature, are present which are foreign to the normal 
feces, — therefore, conditions which favor a bacterial infection. 

A third view, founded by the Breslau school, refers these disturbances 
to faulty nutrition, etc., due to the intermediary metabolism. This theory 
is invoked principally in explanation of chronic digestive disturbances which 
are not to be considered here, and it may therefore be disregarded. 



HISTORY 155 

Parallel with these investigations, and in great part stimulated by them, 
there was a renewed and more profound study of the physiology of the diges- 
tive tract with special reference to problems of artificial nutrition. The inge- 
nious explanations of Boer, Jorg, and Pollitzer, and the anatomical investi- 
gations of Fleischmann may be regarded as introductory. The analytic and 
experimental researches began with the labors of Wegscheider (1875), 
Zweifel, Korowin, Baginsky, Gundobin, and Pfaundler, and demonstrated 
conclusively the functional inferiority of the digestive apparatus, which to 
that time had been only surmised. Of special importance also was the study 
of the intestinal bacteria in the nursling, which was begun in my mono- 
graph, published in 1886, but which has not yet been concluded notwithstand- 
ing the excellent work of Tissier. Finally, we must mention the most recent 
experiments in energy and metabolism which illuminate a new and hitherto 
entirely neglected portion of the nutritive process. 

Thus there has been a complete change in the direction of investigation. 
Whereas formerly the direct discovery of the nature of the disease was 
attempted by careful clinical observation and by the study of pathologico- 
anatomical changes, especially in affections of breast-fed children, which were 
quite properly regarded as the purest types, at the present time we attach 
special importance to investigation of the physiologic conditions. From this 
groundwork the realm of pathology is entered, in that the reaction of the 
intestine to definite irritation has been studied, and the degree of the irrita- 
tion accurately determined. Artificial nutrition, which is in itself no more 
than an experiment on the normal nursling, is incomparably better in these 
physiopathologic experiments than breast feeding wherein a number of un- 
known and incalculable factors must be considered. Besides, it is the kind 
of nutrition which is prevalent to-day and also, as already stated, the most 
frequent cause of disease and death from digestive disturbance. 

It is understood, therefore, that the study of the pathogenesis has devel- 
oped conjointly with the problem of artificial nutrition and especially with 
the observation of artificially nourished infants. Although much labor has 
been expended on this painstaking method, only slight and disconnected 
results have been forthcoming; nevertheless we may hope that eventually, 
by a synthesis of these results, we shall gain a positive experimental funda- 
ment upon which a pathogenesis may be erected. To-day we are far removed 
from such a goal. True, bacteriology has revealed a number of new and 
important facts and has furnished explanations for other already familiar 
data, and in therapeutics and prophylaxis has produced unquestioned results; 
but so long as the connecting link — the knowledge of the toxins and their 
effect upon the infantile organism — is lacking it must remain only a likely 
hypothesis. Even as such, however, bacteriology has greatly influenced the 
investigation of this subject, which has been so long neglected, and the major 
part of our knowledge of the pathogenesis of digestive disturbances and 
almost everything we have learned of the etiology of acute gastro-intestinal 
affections were acquired along this path. Notwithstanding the new view- 



156 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

points which have already arisen in the present century it may for a long 
time govern the trend of investigation. It seems to me well to devote a 
chapter to bacteriology in this article. In the following I shall attempt 
briefly to explain the general conceptions and conclusions that have been 
deduced by recent bacteriologic investigation in the pathogenesis and treat- 
ment of acute digestive disturbances of infancy, and in this connection refer- 
ence must necessarily be made to the earlier researches. 



PHYSIOLOGICAL ASPECTS 

Gastro-intestinal disease always produces a disturbance in the physiologic 
processes; therefore a knowledge of the functional peculiarities of the infan- 
tile organism is absolutely necessary for an understanding of the pathoge- 
nesis. In no organ of the new-born and infant is there such a disproportion 
between functional arrest and requirement as in the digestive tract. I shall 
not enter upon a dissertation of the much discussed deficiency in ferments 
and the muscular weakness of the infantile intestine, but must emphasize 
one point which in my opinion is at present considered much too little. 
This is the shortness of the complete intestinal canal (about 3.5 meters, 
against 8 to 10 meters in the adult), which is not compensated for by the 
great relative length and capacity which are so frequently emphasized. The 
entire length of the bowels of the newborn would extend in the adult only 
to the lower third of the small intestine, and hence it is apparent that, reck- 
oned upon a similar length of the intestinal passage the power of absorption 
is more favorable in the nursling. Nevertheless the shorter length of the 
entire intestine of the newborn and infant together with the smaller number 
and size of the glands permits no more digestive capability that is always 
required for the assimilation of breast milk which the child consumes. Over- 
feeding, especially by artificial means, will exceed this physiologic limit and 
may therefore have a deleterious effect. It is true, a certain excess of breast 
milk, as well as of cow's milk properly prepared and administered, is ingested 
by nurslings without causing disturbance, but the tolerance as opposed to the 
deviation from the physiologic condition, the assimilative capacity for a too 
profuse or foreign food, although it shows individual variation, is neverthe- 
less strictly limited, and becomes more circumscribed the weaker and younger 
the child. This absorptive quality increases markedly during the second 
half-year, and in the further development the digestive organs acquire that 
wonderful faculty of compensation which makes it possible for man to satisfy 
his nutritive requirements under the most varied conditions and zones. 

Furthermore, there is the special irritability and vulnerability of the in- 
fantile mucous membrane to mechanical and chemical stimulation. The 
physiology of the newborn abounds in examples of traumatic effect produced 
by contact with the media of extrauterine life; then how much greater the 
injury from filling of the intestinal canal with food, gases, bacteria, etc. In 



PHYSIOLOGICAL ASPECTS 157 

the mucous membranes which are exposed to contact with the external wall 
we observe a process which we designate as habit or hardening, whereby irrita- 
tion, even feeble or slight, at first produces a severe reaction but eventually 
shows little or no effect. The delicacy of the anatomical relations, the vas- 
cular richness of the mucous membrane (Gundobin), the greater amount of 
water in the tissues, the relative preponderance of the nervous elements, have 
all been invoked in explanation without striking the kernel of the matter. 
Not only is the irritative stimulus decidedly lessened, but also the reaction 
is uncommonly turbulent, for there is an early loss of epithelium, and inflam- 
matory processes develop in the tissues which may distribute rapidly over 
large areas of the intestine and retrogress very slowly even after the irritative 
cause has been removed. This peculiarity has an important bearing on the 
origin and course of the digestive disturbances of infancy, and is all the more 
significant because, in all of the tissues of the infantile digestive tract, there 
is a special susceptibility and predisposition to bacteria and their products 
of metabolism. 

Proof for this is furnished by the pathology of the newborn, which shows 
such a severity, frequency, and multiplicity of septic diseases as is seen at 
no other period of life. To exemplify the special predisposition of the diges- 
tive tract I may call attention to the oral mucosa, which in young children 
is so commonly the seat of mycotic disease, but from the third year of life 
is only exceptionally attacked, notwithstanding the increased opportunity 
for infection. Here, similarly as was demonstrated by Krieger for the respi- 
ratory system, we find a local immunization of the mucous membrane of the 
digestive tract, — a hardening process proceeding downward from above. 
Later we will consider the toxic action exerted upon the nursling by even 
slightly decomposed cow's milk which would not be experienced in an older 
child. 

In positive contrast to these views is the fact that the nursling possesses 
a normal or profuse intestinal flora which apparently exerts no deleterious 
action notwithstanding the fermentative and even pathologic property of the 
bacteria. An understanding of this condition is impossible in the unsatis- 
factory state of our knowledge, but the uniformity of the varieties of intes- 
tinal flora, as well as a study of their biologic properties proves that we are 
dealing with an autochthonous vegetation, suited to the special conditions 
and to the individual, which has no analogy with the bacteria found in cow's 
milk or in the decomposed material. On the contrary, we must assume that 
the intestinal bacteria play a useful role in the process of normal digestion,' 
although by what means is not fully understood. This is obvious from the 
fact that a change of vegetation and the introduction of abnormal fermen- 
tative processes are sufficient to disturb the health of the child and the course 
of its digestion. Such is the origin of the fermentative dyspepsias which are 
peculiar to early infancy. Their frequency is explained when we consider 
that milk, the exclusive food of the child, is especially liable to bacterial 
change and fermentative processes because of its composition and percentage 



158 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

of water; furthermore, in the nursling conditions obtain which decidedly 
favor the entrance and increase of foreign organisms in the intestinal canal. 
Even with a food poor in bacteria, the abundance of the microorganisms in 
the oral cavity will lead to infection of the stomach. Here their brief resi- 
dence, and the admixture of the scant amount of hydrochloric acid already 
present with the salts and albumin of cow's milk, hinder destruction so that 
even normally a large or smaller amount of chyle which contains bacteria 
passes into the duodenum. Strictly speaking, the intestine appears, as is 
obvious from recent investigations, to have a selective bactericidal property 
which is directed only to foreign bacteria, not to those which it requires. 
It is quite likely, although not yet proven, that this protective measure is 
more feeble in the nursling. This is indicated by the care which nature has 
taken to prevent the entrance of germs into the natural food and to avoid 
processes of decay in the intestinal tract. 

Digestive disturbances have an especially deleterious effect upon the 
infantile organism. The milder forms produce fluctuation and arrest of 
the growth of the body, the more severe disturbances lead to a rapid decrease 
in weight and diminish the resistance of the body to all deleterious agents; 
hence they give rise to manifold secondary diseases. In addition, the course 
of these diseases in infancy is relatively brief and pernicious, whereas in the 
adult the affections of this tract are mostly secondary, and are milder and 
more prolonged. 

ETIOLOGY 

The foregoing observations must be borne in mind when we consider the 
causes of digestive disturbance. These may be separated into four groups: 
The first comprises derangements in the anatomical and functional develop- 
ment of the digestive tract. The second group is formed by injurious ali- 
mentation, which may be referred to quantitative or qualitative errors of 
nourishment. The most important among these are the changes due to bac- 
terial decomposition which the milk undergoes within and outside the intes- 
tinal canal. The third group includes the actual infectious processes which 
owe their origin to an invasion of the intestinal tract by pathogenic bacteria, 
irrespective of the nature of the food. In the fourth group are classed those 
causes which have not already been mentioned, such as protozoal, mechanical, 
chemical, thermic, nervous irritation, etc., and especially physiologic condi- 
tions. The essential and most characteristic feature of these causes of dis- 
ease, which, with the exception of the first group, also appertain to adults, 
is this, that even in their milder grades of intensity they act upon the sus- 
ceptible infantile organism with such severity and frequency that more than 
half of all diseases, and a third of all deaths, in this period of life are due 
to them. These children are made ill with food which would be a most harm- 
less sick diet for an adult or even for a child of two years, and it is exceed- 
ingly difficult to determine — in the manner of its acquisition, preservation, 



ETIOLOGY 159 

and administration — the nature of the change which is the cause of disease 
in the individual case. This microscopic smallness of the causes, if I may 
use such a term, is far beneath the stimulus which would be operative in an 
older organism, and is also the reason why this particular realm of patho- 
genesis has been entered so late and only with resource to newer methods of 
investigation. 

Group I. — The first group, the anatomical and functional insufficiency of 
the digestive apparatus, shall be only briefly considered. The cause is obvi- 
ous, and is also the result of undigested remains of food in the feces, com- 
monly known as dyspepsia, so-called by Bamberger. If the activity of the 
digestive apparatus is defective or insufficient for physiologic requirements, 
we speak of an organic dyspepsia. If, upon the introduction of an amount 
of food greater than the individual property of assimilation, there is a dis- 
proportion between requirement and activity, which has already been con- 
sidered, we are dealing with an alimentary dyspepsia. This forms the transi- 
tion to the second group of alimentary deleterious causes. 

Group II. — The food, as well as the excessive introduction of fluid which 
is not absorbed in the intestinal canal, produces under some circumstances, 
as in nutrition with cow's milk, an abnormal weight and damage to the mus- 
cular elements by a clumpy coagulation in the susceptible digestive organs 
or by direct mechanical irritation. This condition is much aggravated by 
the undigested residue of food, which produces a change in the chemical com- 
position of the intestinal contents and a disturbance of the normal vegetative 
relations. The rapid and complete absorption of the mother's milk is 
undoubtedly one of the most essential requirements for the maintenance and 
uniformity of the normal intestinal flora. A change in these conditions, 
even such as occurs in nutrition with carefully sterilized cow's milk, gives 
origin to other vegetative and nutritive conditions of bacteria and also to a 
change in the secretion, the reaction of the intestinal contents, and the peri- 
stalsis, which cannot be calculated. As a matter of fact, in the feces even 
of children nourished with cow's milk and who show no symptoms of disease, 
a bacterioscopic picture is presented which deviates from the norm, in that 
we see more or less facultative, saprophytic bacteria in addition to those 
which are commonly encountered. This proves that the bactericidal faculty 
of the intestinal canal is weakened by these conditions and its resistance to 
the colonization and increase of foreign microorganisms is much diminished. 
In this sense Biedert may quite properly refer to " deleterious remains of 
food," or, more correctly, to " deleterious agents of the food," because every 
deviation from physiologic conditions creates a breach in the thin boundary 
line which here separates the normal from the pathologic. 

However, these deviations have more of a predisposing influence so long 
as they are not combined with definite bacterial processes, and are only excep- 
tionally of substantive pathogenic importance. 

The assumption of a special damage from bacterial decomposition of the 
milk or of the intestinal contents is based upon the statistical fact, already 



160 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

mentioned, of the much greater morbidity and mortality of artificially nour- 
ished children in general, and especially during the hot season. We might 
mention a third factor, the social life, to which all writers upon the mortality 
of nurslings refer. But this influence is operative only in the sense that 
deficient care in nursing and cleanliness, which is common among the poor, 
tends to a greater contamination and decomposition of cow's milk because 
of its much more complicated preservation and preparation, especially during 
the summer. 

Prausnitz demonstrated in his Graz statistics that the wealthy classes are 
not represented in the official lists of infant mortality in the gastric and 
intestinal affections, therefore we may set aside the objection propounded by 
Flligge that the introduction of the Soxhlet apparatus has caused no decided 
decrease of gastrointestinal affections in the mortality of infancy. Those 
classes of the population for whom the Soxhlet apparatus is available are 
largely or altogether excluded from the statistics. Besides, the personal 
experience, no matter how limited, of every pediatrist, proves that natural 
germ-free food is far superior to artificial nourishment with its deleterious 
effects of heat and uncleanliness, or to the employment of sterilization. I 
shall not therefore exemplify these statements but will now give more de- 
tailed consideration to the changes which bring about decomposition. 

The view that the germs which inhabit cow's milk are the cause of diges- 
tive disturbance was first promulgated by Hessling (1866) and Meissner 
(1878), although Bednar (1850) had already quite correctly associated the 
diarrheic discharges of nurslings with fermentating milk. But not until the 
introduction of Koch's method was it possible to estimate the number and 
nature of these germs. In collaboration with Dr. Knopf (1889) I have cal- 
culated that in milk obtained by cleanly methods the number of germs, a 
few hours after milking, averages one-half to one million per cubic centi- 
meter. 

The so-called spontaneous lactic acid fermentation of milk which ensues 
immediately after milking is not, as Pasteur presumed, a uniform process, 
but is due to a number of schizomycetes, among which we may distinguish 
saccharolytic, proteolytic, and perhaps also pathogenic bacteria. The sac- 
charoses are the richest and most numerous group and are represented by 
several varieties. They decompose the milk sugar and produce organic 
acids, thereby inhibiting the increase of the proteolytes and finally of all 
bacteria with the exception of some few acidophilic varieties. 

The nature and rapidity of these processes is dependent upon the micro- 
organism, upon the time which has elapsed since milking, and upon the 
temperature at which the milk is kept. In another article (Wiener med. 
Presse, 1889) I have stated that the height of the temperature is of influ- 
ence not only upon the number of bacteria but also upon the nature of decom- 
position, in that milk kept at a high temperature (35° C. — 95° P.) propa- 
gates microorganisms — probably toxic bacteria and products of metabolism 
(succinic acid, alcohol) — which do not develop in milk kept at a lower tern- 



ETIOLOGY 161 

perature. Young dogs were made ill with milk kept at the body tempera- 
ture and one of them succumbed with choleraic symptoms, while milk from 
the same source, kept at a lower temperature, was administered without 
effect. These observations, together with those of Scholl and Schierbeck 
regarding the greater virulence of fermentative bacteria in summer, explain 
the increased toxicity of milk during the hot season. Accurate chemical 
investigations in regard to the formation of toxic substances are unfortu- 
nately not at hand. Vaughan reports the isolation of a toxin-forming coli- 
like bacillus, and a toxin produced by it which he designates tyrotoxicon. 
The action could only be observed in young mammals, which perhaps have 
the same susceptibility as the child. Thus far we can only presume their 
presence when the milk shows evidence of advanced bacterial decomposition. 
As a matter of fact E. Plant has demonstrated that milk which has been 
kept in the homes of children who have been attacked by summer diarrhea 
has a very excessive acidity. 

Milk that has been incompletely sterilized undergoes a different change, 
whereby the asporogenic varieties of saccharolytes are mostly or entirely 
destroyed and the resistant proteolytic and anaerobic bacteria as well as 
others which have accidentally gained entrance to this media multiply un- 
hindered. Although the pathogenic importance of the proteolytes and 
anaerobes has been greatly exaggerated, nevertheless toxic substances may 
develop even after sterilization if the milk is kept a long time (Carstens). 
In how far the toxins which are formed in fresh and in incompletely steril- 
ized milk are influenced or destroyed by heat is unknown, but clinical expe- 
rience favors the view that milk which is much decomposed cannot be made 
altogether harmless even by prolonged sterilization (Marfan). 

All of these processes which run their course in the milk outside of the 
body I designate ectogenous milk decomposition, in contrast with bacterial 
decomposition which the milk or its individual constituents undergo in the 
intestinal tract after ingestion. As is well known, a bacterial decomposition 
of the milk sugar occurs normally from autochthonous bacterial vegetation, 
especially of the bacterium lactis aerogenes. This process, by maintaining a 
moderately acid reaction and forming gases which fill the intestinal coils, 
may serve a useful purpose. The coli-, anaerobic, and acidophilic vegetations 
which predominate in the large intestine of the breast-fed nursling do not 
attack the residual food. According to Biedert, in children nourished with 
cow's milk the unabsorbed casein produces a normal process of decomposi- 
tion which can be distinguished by the alkaline reaction and by the odor. In 
view of the frequent confirmation of the lesser tendency of casein to decompo- 
sition further proof must be forthcoming to determine whether, in this not 
unusual process, there is a change in the increased intestinal secretion. Unfor- 
tunately, even in the digestion of cow's milk, we lack a knowledge of the 
usual method of bacterial decomposition. 

The pathologic deviation may occur as an excess of this normal process, 
whereby the abnormal amount of acid produces irritation of the intestinal 
12 



162 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

wall. Baginsky has assumed that the bacterium perishes in its own acid 
and that other bacteria do not enter until it has succumbed. 

I believe that an excess occurs especially from the distribution of the 
bacteria in the intestinal canal, in that this process, which is usually limited 
to the small intestine, invades the entire length of the intestinal canal when 
carbohydrates are introduced in large amount or are slowly absorbed. Then, 
in addition to the symptoms of acid diarrhea and remains of sugar or starch, 
we find large numbers of the bacterium lactis in the feces. Booker has also 
observed the frequent appearance of the bacterium in the diarrheic dis- 
charges, but he regards this only as the result of the more rapid evacuation 
of the intestinal contents. 

Much more frequently we observe that foreign vegetation ejects the normal 
and occupies its place. This occurs most simply by a direct continuation of 
the ectogenous fermentation, as after the ingestion of decomposed animal 
milk. In other cases these germs are accidentally introduced with the food, 
with the saliva, or otherwise, and find opportunity for accumulation (chyme 
infection) in their passage through the intestine. However, such an increase 
cannot be considered unless the normal process of digestion has previously 
been destroyed and the bactericidal power of the intestine weakened. 

The nature of this decomposition which takes place in the intestinal 
canal follows the same laws as those which are operative outside the body: 
So long as there are soluble carbohydrates (milk sugar) in the intestine the 
decomposition is saccharolytic, and at the same time the resulting acid 
reaction prevents the development of putrefactive processes (Hirschler, 
Seelig). Putrefactive changes of this nature are possible only in the lower 
parts of the intestine, where the sugar has already disappeared by resorption. 
This eventually leads to the formation of offensive products and an alkaline 
reaction, and I have therefore designated the process alkaline fermentation 
(1889). Here, as already mentioned, the albuminoid secretions of the intes- 
tine, which are readily decomposed, are active and very likely preponderate. 

Furthermore, according to the latest investigations of Tissier, anaerobic 
bacteria, which find suitable conditions for their development in the intestinal 
tract, may give rise to disease more frequently than was previously assumed. 
I can present only a single observation in proof of this, — a case of very acid 
effervescing feces with the odor of butyric acid, in which the anaerobic 
immotile bacillus butyricus (Botkin) could be demonstrated in large num- 
bers. Unfortunately, notwithstanding the extensive bacteriologic examina- 
tions of the dejecta, very few tangible facts in this direction have been 
obtained. 

This lack of result is especially true as regards the generators and the 
products of acid fermentation. In this direction there are no definite reports 
with the exception of the demonstration of butyric acid by Ludwig (reported 
by Widerhofer), and Schlossmann's report regarding the probable fate of 
starch in the intestine of young children. On the contrary, the attention 
of investigators was devoted to albumin decomposition, which Baginsky 



ETIOLOGY 163 

regarded as the principal source of intestinal intoxication. In his report of 
1891 he infers that saprogenic germs are primarily capable of forming toxic 
peptone-like bodies from the albumin present in the food until the produc- 
tion of a decided quantity of ammonia concludes the process. The totality 
of the substances formed and their entrance into the lymph tracts and cir- 
culation are the cause of the severe clinical symptoms. Up to now only the 
proteus vulgaris has been isolated as a generator of decomposition (Booker), 
while the bacillus putrificus coli (Bienstock) has been found in meconium 
but not in the feces. 

In my opinion Baginsky has exaggerated the importance of the processes 
of decomposition in pathogenesis. Casein, the principal proteid of milk, 
tends but little to decomposition and when such a process occurs in the intes- 
tine of the nursling I rather agree with Czerny that it is due to the readily 
decomposed proteids of the intestinal secretion. Furthermore, the most severe 
toxic symptoms such as are seen in acute cholera infantum, run their course 
with a decidedly acid reaction of the intestinal contents and of the feces. 
Further research must explain this apparent contradiction. The toxins 
arising in milk and in the intestinal tract need not, as was for some time 
supposed, owe their origin to destruction of albumin bodies, but may be 
formed synthetically, as Blumenthal has shown, by saccharolytic bacteria. 
I would also suggest that although all of these processes depend upon the 
presence of bacteria, with improvement in our technic we may discover 
microorganisms which are common to all processes of fermentation and de- 
composition. 

I have proposed the term chyme infection for the endogenous processes 
of decomposition, i. e., those occurring in the intestinal canal, to denote that 
this change first occurs in the intestinal contents at its expense and with a 
change in its chemical composition. The intestinal wall is only indirectly 
affected by irritating products thus formed; the remaining organism by the 
absorption of contingent toxic material. 

Group III. — The third group, true intestinal infection, disease of the 
intestinal wall itself, is in contrast to this in that the surface becomes the 
site of an infectious catarrh likewise as in the bronchial mucous membrane, 
or where there is a direct invasion of the mucosa by specific tissue parasites. 
This is analogous to the localized intestinal infections of adults: enteric 
fever, Asiatic cholera, and dysentery. A typical example of infectious catarrh 
is furnished by staphylococcus enteritis of over-fed breast children, explicitly 
described by Moro. In these cases the pathogenic agents are probably identi- 
cal with the staphylococci found in stagnant breast milk. Streptococcus 
enteritis — pyocyaneus diarrhea — also belongs to this group. In fact the 
majority of microorganisms pathogenic in man, especially those endowed with 
septic or pyogenic qualities, are capable of producing infectious catarrhs or 
inflammations when they accumulate in the intestinal tract. 

The conception of these cases is similar but is not entirely parallel to 
Epstein's view, according to which gastro-enteritis, no matter under what 



164 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

name all of the inflammatory intestinal diseases have been included, is only 
one of the many expressions of a septic general infection. We both admit 
that the ordinary causes of sepsis are capable of producing this disease, but 
Epstein believes that the intestinal disorder represents only a partial 
phenomenon of septicemia, no matter how acquired, while I would exact, 
for the assumption of a primary intestinal infection, the proof that the 
pathologic process has originated in the intestinal canal, and eventually also 
the demonstration of the pathogenic cause in the diarrheic discharges. Cor- 
responding to the nature of these bacteria there is usually a deep lesion of 
the tissue and in some instances even the development of sepsis from the 
intestine. This process, however, apart from the agonal invasion, is rarely 
observed and has thus far been demonstrated conclusively only in strepto- 
coccus enteritis. 

The much more common form, which has become familiar from the excel- 
lent descriptions of Fischl, shows an inverse type wherein the diarrhea occurs 
in the course and as a partial phenomenon of sepsis, which usually originates 
by inhalation. However, I believe it to be more correct to include these 
under symptomatic diarrhea. In some few cases, it is true, it may be difficult 
or even impossible to decide whether we are dealing with a primary localiza- 
tion of sepsis in the intestine or with a symptomatic diarrhea following 
general sepsis. Mixed forms may also occur; for example, an ulcer in the 
mouth may lead to general infection, and simultaneously, by swallowing 
the pus, give rise to an infectious catarrh. This disputed question is of 
secondary importance, however, to the fact that here the disease is not caused 
by saphrophytic or fermentative bacteria but by specific organisms pathogenic 
to man which are independent of the nature of nutrition and climatic in- 
fluences. This contrast is most noticeable in foundling asylums, where these 
diarrheas occur with special frequency and severity among the breast-fed 
children, and particularly in the cold season when there is usually over- 
crowding. This affection was for a long time supposed to be a peculiarity 
of such institutions, until the investigations of Lesage, Eossi, Finkelstein, 
and others showed that epidemic diarrhea was not uncommon even among 
artificially nourished children. These observations, together with the accu- 
rate histologic findings of Booker, led to a more accurate study of the schizo- 
mycetes present in the evacuations of such patients, and in some cases at 
least I found a characteristic fecal picture. The cases sometimes occur 
sporadically, sometimes in epidemics, or they jrslj appear in groups and are 
then further distributed by contact infection. This epidemic distribution, 
which is common to older children, colitis infectiosa, as well as that described 
in the Jahrhuch fur Kinderheilkunde, Bd. LII, belongs to bacillosis. In 
the former it appears that there are microorganisms belonging to the coli 
group which confer immunity and may be recognized by the serum reaction. 
In all essentials they coincide with the generator of dysentery, described by 
Celli, Shiga, and Kruse, but in my cases no connection with dysentery could 
be demonstrated. According to our present knowledge the bacilli found in 



ETIOLOGY 165 

" bacillosis," stained by Gram's method and cultivated, I should include in 
the group of the acidophiles, which, as was shown by Finkelstein, also includes 
pathogenic microorganisms. I have formed no opinion of the nature of the 
pathologic process observed at that time. 

The pathogenic faculties of the bacteria common to the feces of milk- 
fed children permit them under certain circumstances, like foreign infectious 
germs, to enter into the blood and the tissues. 

Group IV. — The fourth group affords but secondary consideration in our 
discussion. There are few reports of the appearance of protozoa in nurslings 
— helminths may be entirely disregarded. In a limited number of affections 
I have observed the Lamblia intestinalis (megastoma enter icum) with amebae, 
as well as a flagellate variety. In the last case only, which was published 
in a report of Cahen (Deutsche med. Wochcnschrift, 1891) was I inclined 
to regard these as the cause of the symptoms. Epstein reports that during 
an epidemic among the nurslings in his foundling asylum a protozoon, desig- 
nated monocercomonas, was found in great numbers in the evacuations. 

The transmission of toxic products from the food to the milk has been 
proven in the human being as well as in the cow. In this way the organisms 
which produce fermentation may cause damage in the intestinal canal. Le- 
sage reports that in the Paris Foundling Hospital, where once a week the 
wet-nurses have a fermentating cabbage as food, one-half of the children 
are attacked with diarrhea. 

This also shows the peculiar sensitiveness of the infantile organism to 
substances which are borne by the adult without injury. The same result 
is observed in cows fed with brewer's grains and swill. However, Soxhlet 
quite correctly asserts that this manner of feeding may also have a directly 
deleterious influence upon the bacteria of the milk by unavoidable contami- 
nation of the latter with particles of feces. 

That thermic influences, especially cold, may stimulate peristalsis and 
cause thin, fluid stools is well known to everyone who has studied metabolism 
in infants. Meinert is of the opinion also that excessive heat may give rise 
to choleraic symptoms. Mechanical irritation of the intestine is due to the 
presence of foreign bodies, undigested particles of food, and hard, fecal 
masses. The teaching of dentition diarrhea originates from a period when, 
in the absence of other recognizable cause, gastro-intestinal diseases were 
assigned to an external conspicuous process of development — dentition. The 
so-called ablactation diarrhea (weaning diarrhea) was much more justified 
and its origin from alimentary deleterious substances is readily understood 
because of the inadequate knowledge of the food requirement of nurslings. 

The only time when we are warranted in speaking of a physiologic intol- 
erance is upon the first introduction of food into the intestine of the new- 
born, previously mentioned, and perhaps the colonization therein of bacteria. 

The foregoing causes of disease are by no means of like importance. In 
the development of acute affections we note their frequent combination : those 
which belong to the second and fourth groups are predisposing, and the 



166 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

bacterial invasion represents the inciting factor. A certain degree of alimen- 
tary dyspepsia is exceedingly common in artificially nourished children; in 
fact it is almost " physiologically " present. Here also, as Pfaundler has 
shown, we almost invariably find disturbances in the anatomical function of 
the stomach which favor the development of abnormal decomposition. As 
stated above, the bactericidal faculty of the digestive apparatus is lessened, 
the infection of the intestinal contents or of the walls of the intestine is 
facilitated. It would seem that in artificial nutrition with cow's milk, which 
is so liable to undergo change, the numerous opportunities for infection can 
only be avoided by special prophylactic measures or an unusual resistance 
to the development of abnormal bacterial decomposition. In some cases no 
other factors are necessary for infection. It is easily to be conceived that 
germs, which under normal circumstances exist without injury to the intes- 
tinal canal or are destroyed there, may assume the property of accumulation 
and pathogenic action upon the addition of some predisposing cause. 

Furthermore, the artificially nourished infant is much more exposed in 
consequence of the alimentary damage by chyme infection, so frequently 
referred to, than the breast-fed child who in this particular is protected 
by the normal and regular process of digestion. The infectious diseases 
occur in both categories, apparently with a preference for breast children, 
although as Moro has recently shown, these possess a stronger bactericidal 
serum. 

The result of these arguments may be summarized as follows : The insight 
into the microscopic world of the schizomycetes has opened a new era in 
the previously dark realm of the etiology and pathogenesis of digestive dis- 
turbances. We have learned to differentiate two large groups among the 
great number of bacterial processes running their course in the intestinal 
canal, one of which by decomposition of the intestinal contents, exerts a toxic 
effect, and the other, by an invasion of the tissue, is infections. 

The bacteria of the first group are characterized by an energetic property 
of fermentation and decomposition: those of the second by pathogenic facul- 
ties, also by quite different biologic properties. The typical . representatives 
of the one as well as of the other group permit us to recognize these vari- 
ations quite distinctly. But even here there are transitions : Original sapro- 
phytic organisms or bacteria which are normal in the intestinal canal, such as 
the bacterium coli or the bacterium lactis aerogenes, take on invasive prop- 
erties (Baginsky), while typical pathogenic bacteria, such as staphylococci 
and streptococci, obtain the faculty of acid production to a conspicuous de- 
gree. Thus we may observe how both processes follow one another in the 
same case or appear simultaneously, in that the primary chyme infection 
leads to lesions of the intestinal mucous membrane and thereby to the entrance 
of pathogenic bacteria. Here as everywhere we note transitional stages and 
mixed processes that are sharply distinct from each other in their develop- 
ment and nature. Nevertheless we must hold to this differentiation, which 
is applicable in most cases, at least at the onset of the disease, as it possesses 



SYMPTOMS 167 

not only a theoretic value but is of eminently practical importance for the 
proper treatment, as the following pages will prove. First, however, a few 
words must be devoted to the reaction and the changes produced in the intes- 
tinal wall by the entrance of these deleterious agents. 

The diversity of the irritants which act upon the intestine might lead 
us to expect as great a variation in the symptoms. As a matter of fact, 
however, there is a relatively uniform picture. Substances having a toxic 
effect, such as acids, alkalies, gases, increase the excretion of intestinal fluids 
and produce an excessive peristalsis, whereby the deleterious products are 
diluted and removed. Moreover, the epithelium is protected by a tough 
mucous coating which — as Schmidt has shown — in its natural condition is 
very resistant to chemical agents. Only in the severest intoxications such as 
resemble cholera infantum, is there an excessive increase of this mucus, which 
then leads to extensive degenerative changes of the epithelium. Inflammatory 
phenomena are absent or at most quite subordinate (Heubner). 

In the infectious processes we observe the same symptoms, with the differ- 
ence that here the inflammatory reaction (hyperemia, loss of epithelium, 
accumulation of round cells in the interglandular tissue and in the submucosa, 
etc.) appears earlier and is more distinct. To this must be added the demon- 
stration of the pathogenic agent in the intestinal wall and the elective locali- 
zation of the changes, which sometimes predominate in the glandular elements, 
at other times in the stomach or gastro-intestinal mucous membrane. 

SYMPTOMS 

The symptomatology, in so far as it relates to the composition of the 
discharges, has from ancient times been divided into three stages which are 
governed by the intensity of the irritation : 

1. Dyspepsia, or, more correctly, the status dyspepticus: functional dis- 
turbances in the process of digestion without anatomical change in the intes- 
tinal wall; characterized clinically by the great residue of undigested or de- 
composed food. 

2. Catarrh: a peculiar transformation (obstruction by mucus, or edema- 
tous infiltration) of the surface of the mucous membrane, accompanied by 
mild inflammatory phenomena and conspicuous functional disturbances. 
Clinically this is characterized by a decided increase of intestinal secretion 
profusely admixed with mucus. Following the example of West and others 
I have subdivided this large group, contingent upon its resemblance to the 
preceding or succeeding stage, into simple, dyspeptic, alimentary, and inflam- 
matory catarrh (Wiener hlin. Wochenschrift, 1901). 

3. Inflammation: more or less severe anatomical lesions of the intes- 
tinal wall, from the loss of epithelium and dense small-cell infiltration up to 
total necrosis of the superficial layers, fibrinous exudation, ulceration, etc. The 
feces are characterized by numerous blood- and pus-cells, tissue elements, etc., 
and the manifestations of inflammatory catarrh. 



168 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

It is probable that in the not far distant future new methods will arise 
which will bring the entire symptom-complex into a more sharply circum- 
scribed, etiologically rounded, pathologic picture, as has already occurred in 
the group of infectious intestinal diseases. At this time, however, there is 
no other view-point at our disposal for a general division of gastro-intestinal 
affections. 

As a rule chyme infection represents the mild, intestinal infection, the 
severest type of this gradation. We frequently note transitions of the same 
disease from one to another stage in a backward or progressive direction, and 
we are in fact only dealing with a symptomatic division which gains its 
qualification — alimentary, toxic, infectious — from the etiologic standpoint. 

A further and equally important detail in the classification of gastro-intes- 
tinal affections is the localization of the disease in the intestine. Although 
this is often impossible in very young children and when the disturbance is 
protracted, nevertheless in most cases which are observed from the onset, the 
part first affected can be recognized ; thus, in certain infections of the stomach 
or the terminal intestine, the upper portion of the bowel is the preferred point 
of attack with a milk diet, and the lower portion when starchy food has been 
given. Often quite important data for the localization of the catarrh may 
be obtained from the clinical symptoms and from the composition of the 
discharges. In this connection I refer to the excellent exposition of Noth- 
nagel in his Beitrage zur Physiologie und Pathologie des Darmes (Berlin, 
1884). The objections which have been raised to the views of this author 
by A. Schmidt do not have reference to nurslings. 

This differentiation is not merely of theoretic and clinical interest, but 
it has a decided influence upon the proper treatment, by medicaments and 
locally, which, in the gastro-intestinal affections of infancy we must regard as 
one of the most valuable newer attainments of therapy. 

TREATMENT 

Although the discussion of treatment is to be confined to general funda- 
mental laws which are applicable in bacterial gastro-intestinal disease, never- 
theless, on account of the intimate relation of all digestive disturbances, the 
other forms cannot be passed over in silence, especially the dyspeptic condi- 
tions which are of primary importance in the development of chyme infection. 

As has already been explained in the description of the volumetric method, 
artificial nutrition itself produces a certain injury to the digestive apparatus, 
perhaps less on account of the chemical differences in the individual nutritive 
substances as compared with breast milk, than from the improper adminis- 
tration (influx instead of sucking), and from the over-feeding which is so 
difficult to avoid. Therefore I attach the greatest importance to the quanti- 
tative estimation of the individual meal and of the daily amount, as well as 
to the limitation of food to the physiologic requirement (minimal diet of 
Biedert). Observance of these rules will prove the best prophylaxis for diges- 



TREATMENT 169 

five disturbances. Even in the more immune breast-fed children profuse and 
irregular drinking not infrequently leads to disease; how much more so then 
in artificially nourished infants who are subject almost to a "physiologic 
dyspepsia." 

If these slight disturbances are not arrested by removal of the cause the 
bactericidal property of the bowel is weakened and infection becomes pos- 
sible. In children nourished with cow's milk all of the methods must be inves- 
tigated which are operative in sterilization, in cleansing the bottles, nipples, 
etc. ; even in breast children it is necessary to avoid the adherence of bacteria 
to the nipple or their permeation to the milk ducts. 

Cleanliness of the oral cavity is always to be observed. The influence of 
the oidium albicans in the development of digestive disturbances is still under- 
estimated. To overcome the objections of mechanical cleansing of the mouth 
I have advised the employment of a boric acid nipple (1899). A number 
of similar methods have since been proposed. In those cases in which this 
nipple is rejected I permit the infant to suck a brush dipped in a silver 
nitrate saccharin solution, as proposed by Concetti. 

In an alimentary catarrh, no matter where localized, the following points 
are to be considered in the treatment : 

1. Removal of Harmful Masses in the Intestine. — Wherever the pro- 
cedure is possible (stomach, large intestine) this is accomplished most thor- 
oughly and gently by irrigation; in the small intestine by laxatives, castor 
oil, or the old reliable calomel 0.01 — 0.02 per dose, two to four powders 
taken at intervals of three hours until an effect is produced. 

2. Relief of the Abnormal Decomposition. — The most obvious measure, 
destruction of the bacteria by disinfection, is inefficient or impracticable in 
the intestinal canal. Irrigation of the stomach or intestine may be followed 
by weak disinfecting solutions or the internal administration of antiseptic 
remedies, particularly preparations which split up in the intestinal canal. 
Much less dangerous and more effective is the combat of the processes of 
fermentation by the withdrawal of those foods which have provoked this 
condition, therefore, of carbohydrates and particularly sugar in the acid 
fermentations of the upper intestine, and of albumin foods when the decom- 
position occurs in the colon with symptoms of putrefaction and alkaline 
reaction. 

This principle is most sharply defined in the employment of Demme- 
Epstein's albumin water — discovered empirically — for digestive disturbances 
occurring in milk nutrition. The water appears to alleviate the marked irri- 
tability of the gastric mucous membrane in certain of these conditions which 
are but slightly influenced by the small amount of albumin or by the peptones 
or albumoses advised by me. As this mixture is rather difficult to prepare, a 
simple water or tea diet is usually preferred. Marfan states that the child 
should be given the same amount of other fluid as it would take normally of 
milk. The complete withdrawal of milk, even in breast-feeding, is the first 
and most important rule in every alimentary catarrh. This is usually con- 



170 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

tinued for twenty-four hours in mild cases, but in breast children the period 
may be shortened. When there has been excessive over-feeding the milk is 
withheld until the complete disappearance of undigested food from the feces. 
Strongly diluted food may then be instituted experimentally and cautiously. 
Whenever possible it is best to begin with a diet which differs from that 
formerly employed. If the disease appears in milk-fed infants even in the 
first months I substitute weak Nestle's or Kufeke's food (one teaspoonful to 
fifteen teaspoonfuls of water), inversely, in starchy dyspepsia greatly diluted 
milk is administered. In either case we may attempt to establish a diet cor- 
responding to the age of the patient by the cautious addition of milk. 

In the putrefactive processes which run their course in the lower portion 
of the intestine this principle of deprivation is not so satisfactory, for even 
with a complete hunger diet the readily decomposible albumin of the intes- 
tinal secretion is still present. Therefore in these cases a second method must 
be invoked which belongs to the so-called principle of bacteriotherapy. Like- 
wise as putrefaction of milk is prevented normally by the presence of sugar, 
the administration of carbohydrates may combat the existing proteid decom- 
position in the intestines, since they produce a conspicuously acid reaction 
and are only absorbed in the lower portions of the bowel. Therefore a diet is 
required which contains small amounts of starch (Kufeke's infant food) or 
dextrin, 1 as in Liebig's soup or in the most recent modification of Keller's 
malt broth. Enemata of starch have an analogous action. 

The same method is followed by de Jager, who advises sour buttermilk 
in the nutrition of children suffering from intestinal disease to prevent 
putrefaction. In chronic intestinal catarrh, wherein large numbers of proteus 
bacilli pervaded the evacuations, Brudzinski administered, by my advice, 
bouillon and whey cultures of the bacterium lactis aerogenes, with the result 
that the disagreeable fecal odor and the proteus microorganisms completely 
disappeared from the feces. 

3. Care and Support of Function. — Conformable to general therapeutic 
axioms, the diseased organism must be spared as much as possible. This 
rule has already been observed by the diet of tea and later by the high dilu- 
tion of the food. Also, in consonance with the fundamental laws of dietetic 
therapy, we must consider the varying tolerance of the different foods. Albu- 
min and fat are badly borne by the irritable mucous membrane of the intes- 
tine. Carbohydrates are better tolerated and the mucilaginous preparations 
such as salep, rice, and rolled barley, are preferable. The digestive function 
may be directly aided by the administration of ferments which are lacking 
(pepsin, hydrochloric acid, pancreatin, Tipe). 

4. Drug Treatment.— The fourth measure relates to all those drugs 
which oppose the pathologic condition of the intestine, in that they soothe 
or stimulate the mucous membrane by relieving pain and influencing peristalsis 
and secretion. I shall mention only a few examples. One of the most disa- 
greeable symptoms of acute gastro-intestinal disease is the prolonged vomit- 

1 Is changed into sugar too rapidly. — Editor. 



TREATMENT 171 

ing, which exhausts the patient and prohibits the ingestion of fluid. In addi- 
tion to complete rest of the stomach and the cautious administration of par- 
ticles of ice most valuable aid has been obtained from creasote, menthol, and 
cocain. 

After evacuation of the intestinal canal I employ the old reliable bismuth, 
preferably the salicylate (5 — 100), and when there is colic or permanently 
increased peristalsis I do not hesitate to give small doses of opium, one to 
two drops of the tincture to 100 of the mixture, or enemata of a correspond- 
ing dose. More caution is necessary in the administration of atropin sulphate, 
which I have employed since 1890 (Inaugural Dissertation of Weinbuch, 
Munich) in profuse serous discharges for the inhibition of secretion, occa- 
sionally with remarkable results. 

E/. 

Atropin sulph 0.01—10 

Sig. : One or two drops in fifty of fluid, to be taken in the course of 
the day. 

Dobroklowski has furnished experimental proof for the action of this 
drug (cited by Lukjanow, Pathologie der Yerdauung, 1899). When the 
remedy is administered we must be mindful of dilatation of the pupil, 1 in- 
creased pulse, erythema and sudden rise of temperature, which are common 
consequences; in no case has there been a serious result. Only in subacute 
and chronic affections do I employ astringents, of which there are various 
tannin combinations. 

A further discussion of indications and the treatment of the individual 
symptoms does not come within the scope of these general considerations. 
From the foregoing it will be seen that we possess remedies which will effect- 
ually counteract and abort the abnormal processes of decomposition by the 
rapid and thorough removal of the deleterious contents of the intestine and by 
preventing the further entrance of fermentative material. If the results are 
nevertheless incomplete, this is because the physician rarely has opportunity 
to observe these cases from the onset, but is usually consulted after anatomical 
lesions and permanent disturbances of function have occurred. This gives 
time for the cultivation of the ground upon which chronic catarrh with a ter- 
minating atrophy, relapses, infectious catarrh, and, finally, severe inflamma- 
tory conditions develop. Death is only too often the outcome of these affec- 
tions, which at the onset are usually harmless and relatively easy to combat, 
and is an especially common termination when the hygienic conditions are 
unfavorable. 

The circumstances are quite different in the second group of bacterial dis- 
eases, the intestinal infections. Here the physician is almost helpless in the 
developed disease. The abortion of the process by laxatives or disinfecting 
remedies is hopeless in the present state of our knowledge. Although a cer- 

1 Which is not the first or most prominent effect of belladonna at this stage. Flushed 
cheeks appear first. — Editor. 



172 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

tain influence may be gained by antiseptics over the bacterial processes going 
on in the intestine, nevertheless we cannot consider a disinfection in the sense 
of destruction of certain or all of the pathogenic agents. Neither are we able, 
by passive immunization or the introduction of alexins, to increase the resist- 
ance or the bactericidal property of the body, although such an attempt has 
been made in diseases produced by bacteria of the coli group. The infantile 
organism must therefore depend upon its own powers. 

However, not so much the reaction comes under consideration which is 
brought about by ejection of the noxious agent or by depriving it of power, 
as the bactericidal properties and the local or general immunity which follows 
the infection. We know very little of the factors which are operative here, 
but next to the inflammatory leukocytic wall, the marked increase of intestinal 
secretion, irrespective of the intake of food, is certainly a most efficient pro- 
tective measure. The characteristic bactericidal properties have been only 
recently discovered. In acute cases independent bacteriologic investigation of 
the feces reveals a much diminished permeation of the mucous fragments by 
bacteria, which are grouped in small clumps or zooglese, I might almost say 
agglutinated. In contrast to this there is a more uniform permeation of the 
fecal masses, a more profuse and qualitatively different vegetation. In chronic 
exhaustive diarrheas I have seen conspicuous bacterial decomposition and a 
fluidification of the mucus, with brownish, soup-like stools, which are prob- 
ably the evidences of complete destruction of the bactericidal power of the 
organism. The course and termination of these affections will depend essen- 
tially upon the biologic property of the individual pathogenic agent. In one 
case the toxic, in another the infectious symptoms will preponderate ; as a rule, 
however, the pathologic picture will be of fulminant type from the onset and 
the entire organism will be involved much more extensively than in the pre- 
ceding group. 

In the absence of specific remedies the treatment must be purely sympto- 
matic. First the intestine must be emptied, provided such a result has not been 
already accomplished by vomiting and diarrhea. In any event I cautiously 
employ castor oil, either with or without resorcin, and avoid irrigation of the 
stomach and intestine. Calomel should not be administered as it produces 
irritation. The evacuation of the digestive organs and the brief withdrawal 
of food permit the intestine to concentrate its entire power upon the destruc- 
tion of the pathogenic agents. Special stimulation of intestinal secretion by 
laxatives, advised by Kohlbrugge, is uncalled for. A most important object 
of treatment, however, is the maintenance of a quantity of fluid sufficient to 
play upon the lumen of the intestine, as is provided by nature. As the inges- 
tion of liquids is prohibited by vomiting, the subcutaneous injection of normal 
salt solution must be employed. 

Here as in all infectious diseases our most important aim is to maintain 
the natural resistance of the body. Therefore, after a short interval of absti- 
nence from food, corresponding to the condition of the intestine, we must 
administer stimulating nourishment (meat broth, beef tea, gelatin, wine whey, 



PROPHYLAXIS 173 

etc.). In affections of the colon those foods which contain starch (Liebig's 
soup, etc.) are preferable because they diminish the danger of decomposition 
of the secretion. 

The severity of the constitutional phenomena and the implication of other 
organs call for careful and individual management of the symptoms. How- 
ever, the physician will be able to exert but little influence on the decisive com- 
bat between the infection and the organism which so often has an unfavorable 
termination. On the other hand a wide and fruitful field for his activity will 
be found in prophylaxis. 

PROPHYLAXIS 

Specific general infections due to definite, sharply characterized micro- 
organisms from the intestine appear to be rare in infancy, aside from those 
diseases which occur in general epidemics. Usually in this category of cases 
we have to deal with infectious catarrhs, which, judging from the pathogenic 
agents thus far isolated, are commonly produced by septic or pyogenic bac- 
teria, such as are often found attenuated on the surface and in the surround- 
ings of the human body. While in the latter condition they are usually sap- 
rophytes, they may under certain circumstances develop pathogenic properties 
in the sensitive infantile mucosa. This view is favored by the fact that such 
affections show a preference for crowded habitations and where human ejecta, 
filth, and moisture abound, briefly, where all of those conditions prevail which 
favor the increase of bacteria. The microorganisms gain entrance to the 
body with the food and saliva by the common use of eating utensils or by the 
hands, perhaps also with the inspired air, and find their way into the intes- 
tine, so that with a certain degree of justice we may speak of miasm. Milk 
is often the carrier of infective bacteria from diseased cows or from the con- 
taminated atmosphere of the stable, as is obvious from the presence of strep- 
tococci in the milk. The staphylococcus enteritis of breast-fed children must 
also not be overlooked. The most important and dangerous source of these 
infectious products, however, is furnished by the fecal discharges of the sick. 
These abound with pathogenic agents which have a conspicuous infective 
power, and under suitable external conditions give origin to group diseases 
by contact infection. 

The noncommunicability of cholera infantum has long been considered 
a peculiarity in characteristic contrast to cholera Asiatica. Since, however, 
the attention of the profession has been directed to the epidemic distribution 
of cholera infantum the number of such observations has rapidly increased. 
The extensive investigations in the Foundling Asylum of Prague (Epstein), 
the reports of Finkelstein from Berlin, of Berton from the Graz Clinic, have 
all shown that a determining influence upon the morbidity and mortality of 
foundling asylums is exerted by these affections. 

The methods of distribution of this hospital infection depend primarily 
upon the nurses who care for the children and remove their soiled diapers. 



174 ACUTE DIGESTIVE DISTURBANCES OF INFANCY 

The infectious principle may find its way from the nurse into the food, the 
nipple, or directly into the oral cavity of the child. But the numerous reports 
of hospital epidemics show that infection may be transmitted also by means 
of the child's hands, the diapers, thermometers, instruments, or the commode. 

This gives a basis for active prophylactic measures. Airy, dry rooms, 
avoidance of crowding, careful nursing, and scrupulous cleanliness are neces- 
sary for the welfare of the child not merely for general hygienic reasons but 
also to prevent the development of infectious intestinal catarrh. The nurs- 
ling provides an exceedingly sensitive reagent for the presence of pathogenic 
organisms, and in this connection the intestinal mucous membrane does not 
hold an exceptional position. Therefore, as I have already explained in 
another place (Deutsche med. Wochenschrift, 1898) there must be a certain 
degree of asepsis in the child's surroundings analogous to that of the obstet- 
rician or surgeon, and experience has already taught that by this simple 
means we may bring abo.ut a betterment of the results. 

A further principle that must be observed in our children's hospitals, infant 
asylums, and in fact in all places where a great many children are assembled, is 
to prevent the introduction and distribution of infection. Suspicious cases 
should be retained in an observation ward, sick children should be isolated 
from the general wards. As we are dealing with a fixed and readily destruc- 
tible contagium, isolation in a separate space and with a well-trained attend- 
ant is sufficient, or a specially instructed nurse alone may be required. 

Although we thus succeed in preventing the introduction of such diseases 
from without, there remains the danger of development in the hospital patient 
himself, as in institutions an infection by pathogenic germs is sometimes 
wholly unavoidable. Therefore care must be had that in infectious intestinal 
disease the germs are not disseminated, that they do not find their way from 
the ejecta into the food or the oral cavity of the healthy. A most excellent 
proposition is that of Heubner, who requires a special nurse for the adminis- 
tration of food, and a second to remove the soiled clothing and cleanse the 
child. Unfortunately, in institutions this suggestion is as impracticable as 
the requirement that every infant should have a special nurse. In hospital 
practice we must be satisfied if we have one nurse to every four children, 
who carefully disinfects her hands after handling a patient, and that every 
child has its individual thermometer, bottle, nipple, etc. For several years 
we have had in my clinic small cases made of enamelled ware, with doors of 
glass, fastened to the wall at the head of the bed, which contain the bottle, a 
few nipples, clothes, the thermometer, etc., of each patient. This contrivance 
has proved very serviceable. After an epidemic a thorough disinfection of 
the ward is necessary, preferably with formaldehyd. 

Although these methods fall far short of the theoretic requirement, never- 
theless we can observe with some degree of satisfaction that even their accom- 
plishment has produced a noteworthy improvement in these conditions. Above 
I have called attention to the surprising decrease of mortality since the intro- 
duction of these protective measures in the Foundling Asylum in Prague, and 



PROPHYLAXIS 175 

in the two clinics which first chronicled these hospital epidemics. Since the 
year 1898 there have been isolated group diseases but never again such a great 
mortality among infants as occurred in the epidemic of that year (Jahrb. f. 
Kinderhk., LII). We have every reason to suppose that this is the result of 
the avoidance of contact infection which has been brought about by objective 
protective measures, and I do not doubt that the introduction of improved 
methods, such as have been planned for children's hospitals hereafter to be 
constructed, will produce even better results. Thus we see that these hypo- 
thetic conceptions of the pathogenesis of digestive disturbances, even before 
they have undergone exact scientific proof, have attained practical results 
which incite us to pursue this method still further. 



CHRONIC DIGESTIVE DISTURBANCES OF 

INFANCY 

By B. BENDIX, Berlin 

In the course of his career the physician encounters many forms of chronic 
digestive disturbance in infants. Their comparison, one with another, proves 
them to be entirely different in their etiology, their symptoms, and their 
course, or clinical pictures are presented which, although showing many devia- 
tions, are readily recognized as types of the same affection. The minority of 
these disturbances occur in breast-fed children, the greater number being 
observed in those who are what is commonly termed bottle-fed. 

The irregular course, the varying clinical picture, the incalculable outcome 
of these diseases and the commonly ineffectual therapeutic endeavors, particu- 
larly when contrasted with the acute digestive disturbances of this age, makes 
it obvious how manifold is the relation and how frequently difficult the prog- 
nosis of these chronic nutritive affections. Only by repeated investigation and 
comprehensive study will it be possible to acquire an accurate knowledge of 
the various forms of this disease, which for many reasons are important and 
interesting. 

It appears advisable, therefore, to review the individual types of these im- 
portant infantile disturbances and to arrange them into groups. 

First, it is necessary to call attention to the breast-fed children who for 
weeks present the symptoms of chronic digestive disease. 

Cases are now and then observed of infants who pass thin, greenish-yellow 
or green stools, immaterial whether taking the milk of the mother or of the 
wet-nurse. At first, or intermittently, the stools may show the normal yellow 
color. Frequently they are lumpy and interspersed with small particles. 
Their reaction is very acid; an admixture of mucus is rare. This deviation 
from the normal feces is usually a subacute condition and occurs without 
alarming symptoms. The number of fecal evacuations need not exceed the 
norm (one, two, or at most three daily) ; occasionally there may be four or 
five, but without any increase in quantity, as is the rule in acute gastrointes- 
tinal disturbances, especially in infants nourished with cow's milk. In some 
cases this dyspeptic stool occurs in immediate connection with, or as a con- 
tinuation, so to speak, of the dark meconium of the first days following birth. 
More commonly the movements for some weeks are normal, the disturbance 
arising later. Vomiting seldom occurs; fever is absent. Examination of the 

176 



CHRONIC DYSPEPSIA OF BREAST-FED CHILDREN 177 

abdomen reveals neither pain nor meteorism. An intertrigo of the skin 
readily develops around the anus and upon the upper thigh in consequence of 
the excessively acid reaction of the feces. The disposition of the child does 
not appear to be altered. The weight increases normally. Only in rare in- 
stances, when the affection is much protracted, is there an actual nutritive dis- 
turbance with an irregular or slow increase in weight or even an actual arrest 
of growth. This 

CHRONIC DYSPEPSIA OF BREAST-FED CHILDREN 

does not, as a rule, interfere with the constitutional condition and develop- 
ment. The only symptom that brings the child to the physician is the green- 
ish fluid stool, which continues for weeks. 

In the majority of cases the cause of this abnormality is very difficult to 
discover. The mother or the wet-nurse is perfectly healthy, the interval 
between the feedings is observed according to the physician's advice, and the 
quantity of food is not exceeded. An examination of the milk reveals noth- 
ing further than that the child may be receiving colostrum milk, which we 
know by experience may cause stools of this character. Under some condi- 
tions colostrum may be secreted beyond the normal period, particularly if the 
breast is not completely emptied. This is usually the case when the infant is 
too feeble and its power of suction too slight to overcome the resistance of 
the powerfully developed muscles of the nipple ("schwergehende Brust") 
and sufficiently withdraw the contents of the breast. Digestive disturbances 
may then arise. With experience this may be avoided, as the breast that 
flows freely ("leichtgehende Brust") is of importance in the choice of a wet- 
nurse for a feeble child. In case this requirement cannot be fulfilled — and 
in a large city we are often fortunate to obtain any wet-nurse — the "tense" 
breast of the nursing woman should be given first to a strong child to empty 
in part, and then to the feeble child. 

Only rarely will colostrum be found to have an etiologic significance. In 
those cases in which it plays no part the source of the chronic dyspepsia will 
be very difficult to determine. It would be necessary to assume that these 
dyspeptic infants suffer from a congenital feebleness of digestion, which is 
borne out by the observation that a child of another family, who is subsequently 
nourished by a wet-nurse who was discharged because of the dyspeptic condition 
of the former baby, will thrive and pass a perfectly normal stool. 

The prognosis in this simple dyspeptic disturbance of breast-fed infants 
is always good, although in exceptional cases a temporary arrest of weight may 
occur. The condition may last for weeks or even months — a circumstance 
that is not so remarkable when we reflect that the etiology of this disease is 
obscure and we therefore possess no positive indications for treatment. 

As the cause of this disturbance, in the majority of instances, is to be 
sought in the child itself, the attempt to transfer the infant from the mother 
or wet-nurse to another woman will prove useless, particularly as it is uncer- 
13 



178 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

tain whether the second wet-nurse will be an improvement over the former 
one. Nevertheless, the mother will not be comforted with the statement that 
the dyspepsia of breast-fed children is not serious, and therefore a rational 
treatment of this slight disturbance must be attempted. For this purpose a 
careful investigation of the nurse's general condition, physical as well as 
mental, and of her digestion is necessary, besides a control of the size of the 
meals and the intervals between them. Any irregularities on the part of the 
nurse or mother must be corrected ; improper distribution of the food must be 
regulated. If the feedings are too frequent the interval should be lengthened, 
perhaps to four hours between the meals. 

In some cases examination of the milk reveals an excessive percentage of 
fat. To overcome this condition the breast-milk may be diluted by giving 
to the child, before it is placed at the breast, 50-75 grams, according to age, of 
fat-free bouillon or gruel decoction. 

If it is thought that most of the cases have to do with a congenital decrease 
of the secretory function of the infantile digestive system an attempt should be 
made to strengthen the digestive activity by the administration of stimulative 
or even fermentative remedies. As a matter of fact a speedy improvement 
often follows the so-called ferment therapy. In the order of their digestive 
action the following remedies must be mentioned: pegnin (as much as will 
go on the tip of a knife), lactopeptin, 0.15-0.25 grams, and pankreon, 0.25-0.3 
grams. According to the severity of the case one or another of these drugs 
is given after each meal or every second meal in a small quantity of breast- 
milk. With pankreon particularly I have often seen a complete cure in a few 
days. Good results are sometimes obtained by purgatives, best by 01. ricini 
(!/2 to 1 teaspoonful) given for a few days in succession or occasionally at 
intervals, or, after cleansing the intestine, the ferment treatment is employed, 
perhaps in the form of a simple muriatic acid mixture. 

Only in extreme cases, where these therapeutic measures prove ineffectual 
and regulation of diet, the relief of constipation or other irregularity on the 
part of the mother or wet-nurse are without avail, it is well to wean the child 
or change the nurse. This should be delayed as long as possible, as even under 
new conditions there is no guarantee of success. 

In contrast to those infants whose only symptom consists of an altered 
appearance of the feces, there are breast-fed children who present the clinical 
picture of atrophy, common with artificial nourishment, which will be de- 
scribed more fully later. 

Here we are dealing with infants who are pallid and emaciated. The 
skin is pale or of a grayish tint, the weight has not increased for weeks or 
may even have diminished. The bowel movements of these infants are either 
sluggish, constipated or dyspeptic, or the last two conditions may alternate. 
These nurslings, all of whom present the same miserable habitus of the body 
and the same care-worn expression, have usually been nursed by the mother; 
only a small minority have been brought up by a wet-nurse. The etiology 



ATROPHY OF BREAST-FED CHILDREN 179 

and the history elicited from the relatives of the little sufferer usually coincide 
word for word. 

The mother nurses her own child for two or three weeks; everything goes 
well, then there is an arrest of weight. This arrest, occasionally with an in- 
significant increase, continues for weeks. At first but little importance is 
attached to it, or with a slight increase in weight the anxiety is removed, but 
eventually the profound gradual change becomes obvious to the mother, espe- 
cially if the disturbance be associated with some anomaly in the function of 
the bowels. If the mother of such a baby is questioned as to the condition 
of her milk she will usually reply that the supply is sufficient or that it is so 
abundant that a quantity is discharged in the intervals between the feedings; 
or, as has occurred with me several times, the physician is consulted about a 
breast-pump with which the mother may reduce the excess of milk. 

In the failure to recognize these conditions lies the serious error of the 
mother. Without the slightest suspicion of the fact, her child suffers from 
hunger and gradually passes into a condition of invalidism. The proof of this 
may be readily demonstrated by comparing the daily quantity of milk secreted 
by the breast with the quality necessary for a normal child of the same age. 

The method by which the quantity of milk secreted by the breast is deter- 
mined is of great practical value in the various disturbances arising in the 
nutritive therapy of infants. It can be utilized upon many occasions and in 
addition to many clinical results it is the only positive guarantee as to whether 
the breast supply is enough, too much, or too little. An opinion regarding 
the amount of milk withdrawn can be obtained by weighing the infant before 
it is put to the breast, and again when it has completely satisfied itself. The 
difference in weight, notwithstanding the loss by perspiration, gives a suffi- 
ciently satisfactory idea of the quantity of milk, that is, of the capacity of the 
breast. 

ATROPHY OF BREAST-FED CHILDREN 

If the weighings are taken after each meal for the twenty-four hours a 
decided deficiency will be found in the quantity of the milk compared with the 
normal amount necessary for the growth of the infant. 

In some instances the secretion of breast-milk is so slight in comparison 
with the normal quantity that weaning at once becomes necessary; in other 
cases it is but little less than the norm. 

Figure 1 shows the very characteristic curve of atrophv in a breast-fed 
child (C. P.). 

This child, which was nursed by a mother with an apparently profuse 
flow of milk, within four weeks from birth gradually declined from the origi- 
nal weight of 2,575 grams to 2,510 grams, instead of increasing during this 
period about 600 grams. Upon the first of August (the twenty-ninth day of 
life) the quantity of milk determined by weighing amounted to 335 grams, 
or about one-half of the normal. The addition of a 300 grams bottle of one- 



180 



CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 



half milk at once supplied the deficiency and was followed by the ordinary 
increase in weight. It is of interest to note that the mother, whose daily 
supply of milk was about 400 grams was able to nurse her child for five months 
longer. 



Grams 
4.000 

800 

600 

400 

200 

3.000 
800 
600 
400 
200 

2.000 

1898. 




















































































































































































































































W » 2, 3. * 

S i 

Mother's Milk. 

V 7 11. 18. 25. J 


. 5. 6. 7. 8. 9. 

Mixed Food. 
J 8. 15. 22. 29. y g 



Fig. 1.— Breast-fed child, C. P. Atrophy. 



1899 







Weight 






Date. 


Hour. 


before 


after 


Differene 






nursing. 




1/8 


4 


3490 


3535 


45 grms 


" 


7 


3420 


3460 


40 " 


a 


10 


3450 


3480 


30 " 


2/8 


2 


3430 


3480 


50 " 


a 


7 


3440 


3530 


90 " 


a 


10 


3500 


3530 


30 " 


a 


1 


3450 3500 
In 24 hours 


50 " 




. . . 335 grms 


it 


4 


3450 


3500 


50 " 


(i 


7 


3490 


3520 


30 " 


a 


10 


3120 


3220 


100 " 


u 


1 


3230 


3250 


20 " 


«( 


1 


3440 


3490 


50 " 



With the demonstration of an insufficient secretion of milk, i. e., of a total 
lack of milk in the breast, the etiologic factor of infantile atrophy is found, 
provided we are not dealing with the previously described disproportion be- 
tween a " tense " breast and a delicate child. 

The diagnosis at the same time indicates the method of treatment. The 
only requisite is to supply a quantity of food proportionate to the age of the 
child (perhaps also to the weight) by the addition of some artificial food. 
How much is to be added is readily determined by comparing the deficiency 



OVER-FEEDING OR HYPERNUTRITION 181 

in weight after the feedings with the normal amounts for healthy breast-fed 
children. 

These normal values, which have been obtained from the valuable researches 
of many months by Ahlfeld, Bendix, Feer, Hahnel, Pfeiffer, and others, give 
us an exceedingly clear idea of the requisite and needful amount of fluid for 
infants, and therewith under abnormal conditions a measure for the plus or 
minus quantity in the individual case and a guide for artificial nutrition. 

Nevertheless these figures must not be regarded as an unalterable scheme; 
on the contrary, it must be remembered that every individual is subject to the 
function of his digestive apparatus, to the activity of the glands and their 
varying secretions; consequently one person will satisfy his economy with a 
smaller amount of food than another, yet both will present the same percent- 
age of gain. Thus, it is not remarkable for one baby to require more food, 
another less than is indicated in our calculations. In all cases, however, a 
brilliant and immediate cure will result if the insufficient natural food is 
reinforced by the addition of cow's milk. 

In marked contrast to these atrophic breast-fed infants there is another 
group of dyspeptic symptoms which have been acquired from too frequent or 
too profuse feeding; in other words from a surfeit of food. In a very few 
weeks these infants present the typical picture of 

OVER-FEEDING OR HYPERNUTRITION 

The mother believes the child to be remarkably well-developed and unusu- 
ally healthy, since the weight far exceeds the norm ; it is the so-called " model 
baby," the "mother's pride," surpassing in weight all other infants among 
the relatives and friends. But this happiness of the mother is short-lived. 
Superfluous fat soon appears, the entire body and especially the face has a 
swollen appearance, the complexion is pale and yellowish, the abdomen is dis- 
tended and tense, and colic is common. In addition to these symptoms there 
is often a certain restlessness, which appears early and may cause an increased 
excitability of the motor and sensory nerves (facial phenomenon, timidity, 
etc.), occasionally reaching its acme in eclamptic or tetanic attacks. 

The condition of the bowels in these infants, at first normal, is sooner or 
later changed. Either there is the typical picture of enteritis, the feces being 
voided in small quantities admixed with mucus and accompanied by tenesmus, 
or with hypernutrition the feces reveal the picture of fat diarrhea; the dis- 
charges are bright yellow, homogeneous or permeated with whitish particles, 
somewhat thinner than normal, and with a distinct gloss of fat, frothy, cau- 
dle-like. Microscopically fat globules with the glistening appearance of 
mother-of-pearl, preponderate in the feces in large drops and in clumps. In 
addition scant or profuse quantities of fatty acid crystals are sometimes 
noted, mostly arranged in layers and pointed like blades of grass, but also in 
the more plump, stellate, crossed arrangement or even in amorphous yellowish 
clumps of fatty calcium salts. 



182 



CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 



The diagnosis, which to the experienced physician is apparent from the 
general condition and from the feces, is also revealed to the tyro by the result 
obtained by the scales regarding the amounts of milk consumed. In how far 
the normal quantities of milk are exceeded is shown by Figure 2. 

Treatment. — The treatment of these cases is simple and mostly brings 




Fig. 2. — Infant E. K. Hypernutrition. 



about a relief of the symptoms and a cure. The bowel is first cleansed by the 
administration of a purgative (calomel 0.03, four doses; pulv. Magnes. c. 
Kheo, pulv. glycrrhs. comp. 1-2 grams, or 01. Eicini 3-5 grams. The suc- 
cess of treatment, however, depends upon a careful regulation of the feedings, 
which must not be too short, nor should the child be allowed to completely sat- 
isfy its hunger, thus preventing an excess of nourishment. There are two 



CONSTRICTION OF THE PYLORUS 183 

ways of meeting the last requirement: the child is either kept at the breast a 
shorter time, say ten or fifteen minutes instead of twenty minutes; or the 
weight is taken before nursing and again after a fixed time at the breast. The 
result obtained from the scales is then compared with the figures of normal 
individual feedings for the same age, and whether the child shall be permitted 
to nurse for a longer time depends upon whether the figure is too great or too 
little. After a time a quite accurate estimate can be made without weighing 
as to how long the infant should nurse without consuming too great a quan- 
tity of food. 

A second method for the relief of the condition depends upon the admin- 
istration of a thin mucilaginous preparation or of bouillon free from fat 
before the child is put to the breast, thus partially allaying its hunger so that 
it will take a smaller amount during nursing. 

Now and then the fatty diarrhea due to hypernutrition does not yield at 
once to this dietetic regime; then, as in the case of chronic dyspepsia, pank- 
reon is often of great service. 

Attention must now be turned to a pathologic condition in which the ful- 
minant and characteristic phenomena present a well-marked symptom-com- 
plex, which nevertheless is in such great contrast to the etiology and genesis 
that in spite of the investigations of many physicians ( Finkelstein, Thomson, 
Knopf elmacher, Freund) it is yet unsolved and obscure. 



CONSTRICTION OF THE PYLORUS, PYLORIC STENOSIS, SPASM 

OF THE PYLORUS 

In constriction of the pylorus we are dealing either with a genuine hyper- 
trophy of the muscular layers of the pylorus (organic stenosis) dependent upon 
an anatomical basis, or only with a periodic and transitory spasm of the 
pylorus with a decrease in its lumen. In the wider sense we include with this 
congenital anomaly of the pylorus a well-defined stenosis or spasm in other 
areas of the intestinal canal, especially in the duodenum, but also in more 
remote parts of the digestive tract (enterospasm). Constriction of the 
pylorus may be regarded as the type of these pathologic forms, being charac- 
terized more than any other similar disturbance by the frequency of its appear- 
ance, and impressing its stamp upon the clinical picture by the uniformity 
and clearness of its symptoms. Whether in the individual case we' are con- 
cerned with an organic or functional disturbance can rarely be determined 
with certainty, as the clinical symptoms of both conditions, notwithstanding 
their unlike basis, differ but little except that the severity and duration of the 
pathologic process may awaken a suspicion of an anatomical stenosis. 

Apart from those cases of genuine stenosis or complete atresia, the outcome 
of which is speedy death, the practitioner is chiefly concerned with the con- 
strictions of slight grade or the simple recurrent spasms of the pylorus. 



184 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

Included in this group are a number of cases, mostly breast-fed children, which 
present a peculiar, unmistakable clinical picture that can be produced only by 
pyloric occlusion. 

Symptoms. — The most marked symptom, and one which dominates the con- 
dition, is vomiting in a form which is remarkable for its tenacity and inten- 
sity. A further characteristic is its appearance immediately after the inges- 
tion of food, or rarely later than thirty minutes or an hour afterward. The 
milk is usually uncoagulated and is vomited in large quantities, sometimes 
more than the child has consumed at the meal. According to the degree of 
constriction and the stage of the disease the infant vomits after every meal 
or only after a few, or perhaps merely in attacks, the food being retained for 
a half or even an entire day. The vomitus never contains bile. No matter 
whether such infants are given the quantity of milk appropriate to their age 
or whether this is reduced to a minimum, whether long or short intervals elapse 
between the feedings with a reduction in the quantity of milk, no matter what 
attempts are made to regulate the diet, all are alike useless in arresting the 
vomiting; the attacks return anew. Gastric lavage, even when repeated, does 
not relieve this tumultuous condition of the stomach. 

In some instances vomiting appears immediately after birth, in other cases 
not until days or weeks later, and exceptionally at the end of the second month 
of life. This well-characterized vomiting, occurring as a symptom of spasm 
of the pylorus, is always limited to early infancy. 

If the vomiting does not appear within the first few days after birth either 
there are no disquieting prodromes on the part of the stomach or there is 
merely a tendency to vomit after overloading of the organ with too much 
food. This latter variety, which etiologically is to be referred to injurious 
food and dietary errors, is rare and encountered only in bottle-fed infants. 

The second conspicuous symptom is an abnormal condition of the bowels. 
The stool is scant; constipation for days is the rule. In the well-developed 
disease feces are lumpy, dry, of a dark brown or black color, occasionally con- 
sisting of small, firm balls or particles, " chainlike, resembling sheep-dung or 
coffee beans." The normally soft, pappy consistence which is peculiar to the 
feces of infants in the first half year of life is entirely lacking. Evacuation 
of the bowels never occurs spontaneously but results only after the adminis- 
tration of repeated doses of purgatives or after enemata. Even these remedies 
are often ineffectual. 

In the milder cases periods of amelioration alternate with periods of aggra- 
vation, but here also the feces are in broken particles or formed and are only 
passed with the aid of purgation. 

On account of the slight absorption of fluid diuresis begins to abate: the 
infant is rarely wet. 

As a rule the appetite is good; very frequently there is eagerness for food 
and for greater quantities than would be given normally. While healthy 
infants generally fall into a quiet sleep after nursing, the child with con- 
stricted pylorus writhes and cries as if in pain and does not become quiet until 



CONSTRICTION OF THE PYLORUS 



185 



the stomach is emptied by vomiting. Frequent restlessness and occasional 
whimpering or crying occur also during the intervals between the feedings, 
therefore at a time when the stomach is empty or contains an insignificant 
quantity of food. This symptom favors the fact that the cause of these pain- 
ful sensations, the pathologic contractions of the pylorus, are either perma- 
nent or occur at intervals even when the stomach is empty. 

Examination of the abdomen of an infant suffering from disease of the 
pylorus shows the region of the stomach to be prominent, especially after the 
ingestion of food, and in marked contrast to the retracted abdomen. Occa- 



Birth. End of Week. 
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Fig. 3. — Symptoms: stubborn constipation ; vomiting of nearly every meal, often immediately 
after the ingestion of food; antiperistaltic movements; retracted abdomen. Nervous infant. 
Atrophy. (Rudolph K., born May 3, 1903: spasm of pylorus.) 

sionally by sound palpation or by insufflation of air a visible dilatation may 
be noted and a demonstrable plastic peristaltic movement of the stomach or 
of parts of the intestine may be determined. These conspicuous peristaltic 
movements, which often occur over the abdomen spontaneously or may be 
produced by stroking the belly with the finger or the handle of a percussion 
hammer, are usually wave-like and run transversely over the abdomen from 



186 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

left to right ; sometimes, however, they are " antiperistaltic," proceeding from 
right to left. 

In some well-developed cases of pyloric constriction it is possible to pal- 
pate on the right of the vertebral column a cylindrical, transverse tumor of the 
thickness of the little finger — the contracted pylorus — or at least a resistance 
in the pyloric area. 

At the onset of this digestive disturbance the development of the child, 
usually of normal weight at birth, continues fairly good; later, when vomit- 
ing dominates the scene and less food is assimilated in consequence of this 
symptom, there is an arrest and finally a loss of weight which may progress 
to the most marked grades of emaciation or even to complete atrophy. 

The duration of the disease and its final outcome — atrophy — are natur- 
ally in intimate association with the degree of constriction and dependent upon 
whether the condition is one of organic or functional change. 

I have seen a bottle-fed baby, aged five weeks, which presented all of the 
characteristic phenomena of pyloric stenosis but nevertheless was cured of the 
malady within three weeks. Another case, that of a breast-fed infant, in whom 
the predominant symptom, vomiting, appeared immediately after birth, was 
a cause of great anxiety to the parents for many weeks, and not until the ter- 
mination of the eighteenth week of life was there a permanent gain in weight. 
(See Fig. 3.) 

Prognosis. — In congenital anatomical alteration of the pylorus the prog- 
nosis depends entirely upon the extent of the stenosis and upon the functional 
capacity of the expulsive musculature of the stomach. With moderate steno- 
sis and powerful muscles the prognosis is fairly good. The child who finally 
overcomes the acute perils of a relatively constricted pylorus, which may con- 
tinue until the end of the fourth year, may in later childhood develop a per- 
manent gastrectasis with all of its annoyances and dangers. In absolute 
pyloric stenosis the prolongation of life in the individual case is very ques- 
tionable. Most favorable are the cases of relative stenosis in which there are 
apparently only recurrent spastic constrictions of the pylorus. These simple, 
functional disturbances appear in the majority of cases to be the etiologic 
factor for the severe clinical symptoms, therefore they also furnish the great- 
est contingent in practice. It is a comforting fact for both the physician and 
the parents that patients belonging to this category almost always recover, 
even after the severest atrophy. When the stage of improvement arises, 
although by what means it is brought about is unknown, it is nevertheless 
certain that the change is usually quite sudden and as a rule permanent. 

The pathogenesis requires amplification at many points. 

For many of the cases the question propounded at the beginning of this 
article as to whether pyloric constriction develops from an organic or func- 
tional basis must remain open. In the numerous cases that pass from gradual 
improvement into complete recovery a transitory spasmodic condition of the 
pylorus must be assumed ; in other instances, in which from birth the severest 
symptoms occur acutely, with rapid atrophy, a true congenital pyloric stenosis 



CONSTRICTION OF THE PYLORUS 187 

can scarcely be rejected. As a matter of fact, in a number of children who 
have succumbed to the disease the autopsy findings render this assumption 
positive, since they disclose an anatomical foundation as the cause. The 
necropsy findings and the reports of various authors (Hirschsprung, Finkel- 
stein, Thomson, Stern, Lobker and others) are as a rule conspicuously uni- 
form: The pylorus is usually found as a coarse, hard, cylindrical tumor 
about 2!/2 c m - i n length which is separated externally from the pars pylorica 
by a shallow furrow, and internally by step-like elevations. The lumen of the 
organ has been variously described, sometimes as admitting only a fine probe, 
at other times one of medium size or occasionally of the size of a lead-pencil. 
The mucous membrane at the entrance of the pylorus is deep red and greatly 
congested ; particularly at the point corresponding to the insertion of the small 
curvature of the stomach the swelling stands out valve-like and prominent, 
and, like a valve, occludes the passage to the lumen of the pylorus. The stom- 
ach is enlarged, the wall, and especially the muscularis, greatly thickened, the 
mucous membrane is infiltrated, there is polypoid proliferation, and between 
the glands there is a small-cell infiltration. The hypertrophy implicates all 
of the tissue layers and in particular the muscularis, sometimes with a greater 
involvement of its longitudinal, at other times of its annular musculature. 
Hirschsprung succinctly defines the post-mortem findings of pyloric stenosis 
as " congenital pyloric hypertrophy " and Finkelstein also considers " congeni- 
tal pyloric stenosis " to be responsible for a number of the reported cases. 
The latter author believes the muscular hypertrophy and the gastric dilata- 
tion to be secondary manifestations. He analyzes the condition in the fol- 
lowing order: congenital pyloric stenosis and in consequence stagnation of the 
gastric contents ; then intercurrent dyspeptic disturbances and catarrhal affec- 
tion of the stomach; the swelling of the mucous membrane increases the 
stenosis, the inflammatory infiltration of the walls of the organ paralyzes the 
motor function and leads to gastric distension. With this there is compensa- 
tory and inflammatory hypertrophy of the muscularis. 

In contrast to the explanation of pyloric stenosis as a congenital, organic, 
muscular disease, other authors (Thomson, Pfaundler) have claimed that in 
the pathologic process a firm anatomical obstruction to the passage does not 
exist but merely a " spastic" constriction or a "spastic " closure of the pylorus 
(" congenital " or "idiopathic vomiting" or "congenital gastric spasm," 
Thomson). Pfaundler regards the thickened, rigid wall of the pylorus, the 
lumen of which is so narrowed as to scarcely permit the passage of a thin 
sound, merely as a post-mortem finding, as he was able to demonstrate that 
in infants who had never presented gastric symptoms during life the entire 
stomach or its pyloric portion were occasionally in firm contraction. 

For the origin of spastic pyloric stenosis various theories have been pro- 
pounded. Thomson speaks of a nervous disturbance of the coordination 
activity of the gastric and pyloric musculature so that even in utero, during 
the absorption of liquor amnii, a continuous uncoordinated labor is performed 
by the stomach; other authors refer this uncoordinated pathologic activity of 



188 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

the stomach to the influence of a harmful irritation which the infantile organ 
has suffered post partum. 

From the investigation of my own clinical material, which has amounted 
to eleven cases in the last few years, it is evident that in the majority a nerv- 
ous predisposition has existed from the onset. The infants are restless, fright- 
ened, and present the facial phenomenon, not as a secondary condition but 
primarily, at the beginning of the disease. A number of my patients were de- 
scended from nervous families, and a special predisposition existed in the 
child whose weight curve I have presented; here both the father and mother 
were exceedingly nervous individuals. If we adhere to the theory of a nerv- 
ous predisposition it is necessary to assume that through a certain hypersensi- 
tiveness and perversity of the nervous apparatus of the stomach the filling of 
that organ results in closure of the pylorus. According to Koppen, who 
declares the pyloric spasm to be a congenital, local, constitutional anomaly, the 
hereditary nervous predisposition plays an important role. Also, in confor- 
mity herewith is the peculiar phenomenon of a family predisposition to the 
affection, as has been reported by Henschel, Freund, and others. 

A further indication in the analysis of the nature of pyloric spasm is 
furnished by the verification of Knopfelmacher of the presence of hyperchlor- 
hydria in an infant suffering from pyloric stenosis. This abnormality of the 
gastric juice secretion, which occurs in constriction of the pylorus and similar 
conditions in adults, has also been demonstrated by other authors (Freund) 
in infants with pyloric stenosis. If this gastric hypersecretion of HC1 is 
found to be a common condition in infants with constriction of the pylorus 
it would explain why the disease is so common in breast-fed children, for in 
consequence of the slight amount of albumin in breast-milk there is also a 
lessened property of combination of HC1, hence a plus of free HC1 is present 
which furnishes the irritation for the spasmodic contraction of the pylorus 
upon filling of the stomach. This, of course, would only explain the condition 
in breast-fed infants, and not in all of these, for only in the minority of such 
children has an increase of HC1 been demonstrated. For infants nourished 
with cow's milk, in which with the large amount of albumin present there is 
a greater liability of combined HC1 this explanation is not sufficient. 

Treatment. — In the treatment of pyloric constriction I shall exclude those 
cases in which, from the evidence of the clinical symptoms, we are dealing with 
a congenital organic or absolute stenosis. For these cases a gastro-enterostomy 
has been proposed. It is well, however, not to be too eager to advise opera- 
tion as even the cases of pyloric constriction, apparently the most severe, 
yield to internal treatment, and an operation is no guarantee of a successful 
termination. Surgical intervention should be considered in those cases in 
which vomiting appears immediately after birth and fulminant symptoms with 
rapid decline indicate a serious prognosis — cases which we are certain will 
perish if a speedy operation is not performed. 

In the majority of patients, however, it is advisable to desist from surgery 
and to adopt an expectant or internal treatment. 



CONSTRICTION OF THE PYLORUS 189 

The principal object in a malady in which vomiting is the most prominent 
symptom mnst be to find a food that will agree with the infant. As breast- 
milk, for reasons which need not be mentioned here, is the best and most suit- 
able food, the first thought would naturally be to continue this nourishment 
and also to supply breast-milk to bottle-fed babies. Ultimate recovery from 
pyloric stenosis after the administration of breast-milk has been reported by 
Heubner, Stamm, and others. In a great majority of the cases (in my mate- 
rial 9 times out of 11) breast-milk fails as a remedy for this affection. A 
portion of my patients were nursed by the mother, others by a wet-nurse. 
After several changes of the wet-nurse I was reluctantly compelled to substi- 
tute artificial nourishment for the natural food because of the persistent vomit- 
ing, the stubborn constipation, and the continuing loss of weight. 

On account of the hyperchlorhydria now and then present in pyloric 
stenosis, and of the greatest faculty of HC1 combination with undiluted 
cow's milk, this would be the rational food after failure with breast-milk. 
Thus, Knopfelmacher, Freund and Siegert report cures in pyloric stenosis 
following the administration of undiluted cow's milk. Personally I have 
not employed this method but with the indication given by the hyper- 
chlorhydria for therapeutic measures, and having failed with breast-milk, I 
should first consider this experiment, and would recommend it all the more 
urgently if an increased accumulation of hydrochloric acid were the result. 
Should this attempt prove unsuccessful I earnestly advise a form of nourish- 
ment from which I have seen positive benefit after failure with undiluted and 
diluted cow's milk, Liebig's soup, and other milk substitutes. This consists 
of Biedert's cream mixture, which, under the name of ramogen, is supplied 
by the manufacturer as a conserve as well as in a fresh form ready for use. 
At first I administer this cream mixture cautiously, in small amounts, increas- 
ing the strength and quantity gradually. I have read with much interest 
that the plentiful employment of cream in the diet has also proved useful in 
gastric ulcer of adults by counteracting the effect of hyperacidity, and that 
much may be accomplished by the substitution, so far as possible, of cream 
for the readily fermenting carbohydrates, particularly in those cases in which 
there is a tendency to hypersecretion and hyperacidity (Strauss). 1 

With the administration of Biedert's cream mixture more than with any 
other food it will be noted that the vomiting is gradually decreased, becomes 
less frequent, appearing only occasionally, and finally ceases. 

As to the quantity that is to be given at each meal, in some cases it 
appears to be practically immaterial, so far as the frequency of vomiting is 
concerned, whether the child receives much or little. In other cases the 
patient apparently thrives better with small amounts (20-50 grams per meal) 
as now and then, with this limitation, a meal will be retained by the stomach. 

1 1 do not consider it my domain to criticize, but fat creates fat acid and is not borne 
in gastric ulcer. Its excess — aye, its quantity appropriate in normal conditions — gives 
rise to acid, indicanuria, diacetic acid, and aceton. Carbohydrates are not "readily 
fermenting," just the contrary. — Editor. 



190 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

In these cases, naturally, the intervals of three or four hours between the 
feedings must be shortened to thirty minutes or an hour. Experience has 
taught that it is advantageous to re-supply the stomach with food after the 
vomiting, as then the fluid will often be retained. 

Gastric lavage, which is so valuable in the acute gastro-intestinal affections 
of infancy, not only is of no avail in pyloric stenosis, but through the develop- 
ment or aggravation of gastric dilatation is even a source of danger. Only 
at the beginning of the treatment may lavage be indicated to free the stomach 
of milk and fermentative residues. 

The following drugs are of service in pyloric stenosis, especially for the 
vomiting and the spasmodic contractions associated with pain : 

B/. 

Anesthesin (0.15-0.25) 

One powder thirty minutes before each feeding; opium in combination 
with valerian: 

E/. 

Tinct. Opii gtt. i-ii 

Tinct. Valerian . 10.0 

M. et Sig. Five to ten drops three times daily; or alkalies. 

R/. 

Kalii carb .4.0-6.0 

Syr. Cort. Aurant 50.0 

— ■'.'.' ' Tinct. Opii .gtt. v-vi 

Aq. dest ad. 100.0 

" M. et Sig. One teaspoonful after each meal ; or 

B/. 

Magn. carb 4.0 

Tinct. Opii gtt. v-vi 

Syr. Alth 30.0 

Aq. dest ad. 100.0 

M. et Sig. A small teaspoonful after each feeding; the bottle not to be 
shaken. 

Moist-warm applications or flaxseed poultices applied to the region of the 
stomach and renewed every two or three hours are valuable for the relief 
of pain and to lessen the spasm. Frequent warm baths are of value when the 
pain is intense. 

For the constipation, which, next to the vomiting, is the most prominent 
symptom, and, as has been stated, is very obstinate, enemata of water, oil, or 
glycerin may be employed, or suppositories, high injections, mechanical 
loosening or evacuation of the bowel by means of moderately thick rectal 



CHRONIC CONSTIPATION 191 

bougies. Abdominal massage may also be cautiously tried. In desperate 
cases my greatest success has been from the use of rectal bougies. Although 
purgatives must not be employed regularly, they cannot be dispensed with 
entirely, even if they are only administered at intervals (about every eight 
days) to relieve the bowel of the inspissated residues. Most suitable for this 
purpose is the addition of a few teaspoonfuls of malt extract, given several 
times a day with the food, or 5 to 10 grams of castor oil. 

The constipation regulates itself very gradually; it disappears much later 
than the vomiting, continuing as a rule for weeks or months and even after 
an increase in weight is noticeable. Usually the condition does not disap- 
pear until the infant is transferred from an exclusive milk diet to mixed food. 

Pyloric stenosis has here been described as a pathologic picture of infancy, 
which, although more common in breast-fed children is occasionally observed 
in bottle-fed babies. Another chronic digestive disturbance 



CHRONIC CONSTIPATION 

is also encountered with both forms of feeding, but is most common in artifi- 
cially-nourished infants. By habitual constipation we understand a chronic 
digestive disturbance in which, instead of the normal fecal movements of 
salve-like consistence occurring once, twice or even three times in the twenty- 
four hours, the physiologic action is disturbed, in that the intestinal contents 
are evacuated spontaneously only every two or three days or perhaps not 
at all. In the overwhelming majority of such cases the consistence of the 
evacuated masses is compact, lumpy . or formed, the color brownish-black, 
sometimes actually carbonized. While in many of these cases the only symp- 
tom is the sluggishness of the intestine or coprostasis, in others the abdomen 
is tense and meteorically distended. Also the tongue is coated, the appetite 
poor, and there is a certain amount of restlessness. 

Although the diagnosis of habitual constipation is not difficult the treat- 
ment demands an exact knowledge of the underlying source of the evil. With 
the etiology the direction for therapeutic procedure is indicated. The causes 
of chronic constipation in infancy are various and treatment must accordingly 
be directed to the underlying condition. We have learned that constipation 
is a symptom of hypernutrition of infants and have likewise noted the con- 
dition when insufficient food is administered. It is found under either cir- 
cumstance in breast-fed as well as in artificially-fed children, although breast- 
fed infants furnish the great contingent of the latter group and bottle-fed 
infants of the former. In bottle-fed children the quality of the milk as well 
as the quantity is often an important factor in the development of consti- 
pation : Undiluted milk may occasionally favor this condition in early infancy 
or, inversely, a too great dilution or too great addition of infant food. Now 
and then constipation occurs during the slow healing of a chronic intestinal 
catarrh. 



192 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

Constipation not infrequently occurs during weaning, that is, at the period 
when the child is transferred from milk to a semi-solid or mixed diet. 

In many instances none of these factors is available and the explanation 
must depend upon the so-called atony or debility of the intestinal muscles, 
whether this be congenital or acquired through hypernutrition. As a predis- 
posing factor for this insufficiency the slighter development of the intestinal 
musculature of the infant may be invoked, and even more important is the 
anatomical condition of the colon, which, in proportion to the small intestine 
is much longer in early infancy than in the older child and adult, and at 
the same time by its greater mobility at the mesentery often discloses a more 
or less decided loop formation at the sigmoid flexure. We can therefore ap- 
preciate why, in infancy, there is frequent difficulty in the propulsion of the 
intestinal contents, which results in chronic constipation. 

In very exceptional cases there exists from birth a stubborn constipation 
and distension of the abdomen which may from time to time be increased. 
Upon examination of such patients it is found that thick bougies per rectum 
may be introduced easily and to some distance. Simultaneously there is a 
greater capacity of the large intestine and through the abdominal walls a 
visible dilatation of the colon and a palpable thickening of its walls may be 
demonstrated. For a time the child thrives very well with this condition; 
later, emaciation takes place rapidly, usually complicated with profuse diar- 
rhea, and death ensues from inanition or cardiac asthenia. In some instances 
the patient has been saved by a systematic regulation of the defecations. 
This affection, which is known as 

HIRSCHSPRUNG'S DISEASE 

because of its first recognition by that author, and of which Genersich, Johan- 
nessen, Goppert and Baginsky have since reported cases, in all probability is 
due to a congenital hypertrophy and dilatation of the large intestine which 
may be regarded as an anomaly of development, as the conspicuous meteorism 
and constipation are present at birth. In the cases which have come to 
autopsy an anatomical thickening of all the layers of the intestinal wall has 
been found. Besides this congenital hyperplasia of the muscular layers, how- 
ever, there must be a certain lack of motility and of complete power of con- 
traction to explain why, notwithstanding the hypertrophy, the large intestine 
is incapable of expelling its contents. Stasis of feces and gas still further 
increase the hypertrophy and sometimes gives rise to secondary alterations 
of the mucous membrane (erosions and ulcerations). In the cases which have 
thus far been reported no constriction could be demonstrated in the lower 
portion of the intestine at the internal sphincter. 

In contrast to the general acceptation of this malady as a dilatatio et 
hypertrophia coli congenita Johannessen declares the condition to be acquired, 
upon the basis of the previously described physiologic peculiarities of the sig- 
moid flexure which may under some circumstances in the infant give rise to 






CHRONIC CONSTIPATION 193 

difficult defecation and to a labor hypertrophy of the muscular layers, and 
finally to dilatation of the intestine. 

In another series of cases the presence of superficial or deep lesions of 
the intestinal mucous membrane, 

EROSIONS AND FISSURES 

may reflexly produce constipation in consequence of pain during defecation. 
Although such infants present a very characteristic picture, the condition 
is often unrecognized by the physician because he omits to examine the anal 
mucous membrane for injuries. Infants who have always had normal, pain- 
less evacuations show that they are in pain by crying prior to every bowel 
movement, which still takes place spontaneously. This pain continues during 
or after defecation. Within a few days the sensitiveness during a bowel move- 
ment becomes extreme and in order to avoid the pain the child retains the 
feces as long as possible. The previous restlessness and refusal to attempt 
defecation are even more significant in children about one year old than in 
nurslings. 

In consequence, if the anal fissure persists for some time, small hemor- 
rhoidal nodules often develop at the anus as the result of venous stasis. 



TREATMENT OF CHRONIC CONSTIPATION 

The treatment of chronic constipation and its success depends upon the 
exact recognition of the special cause in the individual case. With the 
removal of the cause the symptom disappears of itself. The constipation of 
breast-fed children is readily relieved. With abundant food, its proper 
assimilation, and the absence of any organic factor, the constipation is re- 
lieved after small doses of tea, meat broth, or malt extract. In more severe 
cases abdominal massage will bring about the desired result. This is per- 
formed by the mother or wet-nurse twice daily, morning and evening, when 
the child's stomach is empty and best after the bath. The movements are 
those of light stroking with the oiled hand along the course of the colon, 
succeeded by kneading of the abdomen. 

These manipulations, although conducted with care, must nevertheless be 
somewhat energetic, if the desired effect is to be produced. 

Constipation, the result of over- and under-feeding, soon disappears when 
the diet is regulated, as was set forth in the discussion of these digestive 
disturbances. 

In Hirschsprung's disease purgatives and daily injections of water into 
the intestine are necessary to bring about an evacuatio alvi. In addition to 
enemata of water Lennander of Upsala advises the employment of electricity, 
one electrode being introduced into the dilated colon, the other being used 
to stroke the abdominal wall. Both methods of treatment promise success, 
for by the evacuation of the large intestine with injections of water as well 
14 



194 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

as by electricity the tonus of the diseased intestinal area is raised, the dila- 
tation decreased, and normal conditions are finally brought about. 

In addition to their therapeutic effect the intestinal washings are also 
an aid in diagnosis. With these injections, in case we are dealing with a 
dilated colon, there is a conspicuously rapid off-flow of the water and an enor- 
mous receptive capacity of the lower bowel thus enabling the infant to retain 
several liters of water. This conspicuous phenomenon, which can be explained 
only by the abnormal width of the large intestine, with the simultaneous pres- 
ence of marked meteorism and stubborn constipation, at once indicates the 
diagnosis to the careful observer. 

Eecovery in dilatation of the colon is not hopeless although in the majority 
of cases the disease is life-threatening. 

For the narrow longitudinal tears of the anus (fissura ani) warm sitz- 
baths, inunctions with indifferent salves, painting with a 2 per cent, silver 
nitrate solution or salve, cauterization with silver nitrate, painting with a 10 
per cent, cocain solution or inunctions with a 5 per cent, cocain salve are of 
service. Ichthyol suppositories are also valuable : 

B/. 

Ammon. sulph. ichthyol 2.5 

Cocain. hydrochlor 0.05 

Ext. Belladon 0.01 

Butyr. cacao Unguent. Cerae q. s. 

f. suppository. 

I have used the suppository treatment in several cases of anal fissure with 
extraordinary results (recovery after 8-10 days) and believe it to be a very 
valuable aid in the cure of this affection. 

Division of the sphincter for the purpose of relieving the tension of the 
lower portion of the bowel and for the relief of pain I have never found 
necessary but the introduction of a metal rectal bougie of the thickness of 
the little or middle finger often produces a gradual, moderate distension of 
the sphincter and relief of the pain. 1 

In the treatment of hemorrhoids sitz-baths and inunctions play an im- 
portant role ; with decided nodular formation an ice-bag is of service. Anusol 
suppositories, which consist chiefly of bismuth, zinc oxid, and balsam of Peru, 
are of advantage. In both anal fissure and hemorrhoids we must resort to 
internal medication for a soft pappy stool. 

The greatest resistance to treatment is presented by those forms of chronic 
constipation in which no obvious cause can be demonstrated and in which, 
therefore, it is necessary to invoke the congenital peculiarity of the infantile 
intestine and the so-called atony in explanation. Dietetic measures should 
first be tried. Accordingly such errors of diet as may exist are corrected 

1 Forcible dilatation is the quickest and easiest remedy. A drop of a \ p. c. solution 
of silver nitrate along the fissure afterwards every 3 or 4 days. Cleanliness. — Editor. 



CHRONIC CONSTIPATION 195 

either by a greater concentration of the milk mixture or by a reduction of 
the milk and a greater addition of water. Sometimes it is possible to influence 
the sluggishness of the intestine by the addition of larger quantities of cream 
or sugar than are customary for a normal child of corresponding age. Sugar 
of milk is not well suited for this purpose but dextrose and malt sugar are 
particularly valuable. 

To every bottle of milk is added one or two teaspoonfuls of a concen- 
trated solution of dextrose (10-20 per cent.), malt powder (Brunnengraber), 
or malt extract (Loefland, or the milk regime is interrupted for a few days 
by the substitution of Liebig's or Keller's malt broth. An increase of fat 
may be produced by the addition to the milk of one-half to two teaspoonfuls 
of cream or butter to each bottle. Fresh butter seems to have a more prompt 
effect than when cooked with the milk. An increase of fat is also brought 
about by the well-known milk modifications, such as Biedert's cream mixture 
and Gartner's fat milk. 1 

Should these dietetic measures prove ineffectual a movement of the bowels 
may be induced by soap or glycerin suppositories, or by the injection of water, 
oil, or glycerin. In very obstinate cases the only alternative is to remove 
the compact fecal masses with a well-oiled rectal bougie or long-handled 
curette, or with the finger. These methods are only successful for the single 
movement; to attain a permanent result particularly in the anatomical con- 
dition, there is no better remedy than abdominal massage, the technic of 
which has already been given. If this method is practised energetically and 
without interruption for four to six weeks the disagreeable condition will in 
the majority of cases permanently disappear. 

At the commencement of this mechanical treatment and occasionally 
during its course we cannot dispense with the administration of a laxative. 
In addition to the plentiful administration of cream and the special prepara- 
tions of sugar the following remedies are useful in infants : 

Oleum ricini 5-10 grams, magnesia 3-6 grams, pulv. magn. cum. rhei 
(Eibke's infant powder) 2-5 grams, pulv. glycyrrhyz. composit. (Kurella's 
powder) 1/2-1 teaspoonful, infus. sennae composit. (Viennese potion) or 
vinum rhei in teaspoonful doses, syr. spin, cervinae s. rhamni catharticae, a 
small teaspoonful, and at the termination of the nursling period pulv. rhei, 
a knife-tip full, etc., etc. 

In conclusion I must call attention to the influence of prophylaxis, or 
ihe early and persistent treatment of chronic constipation in infancy, upon 
the frequency of that condition in advanced childhood and in puberty, which 
indicates the necessity for employing all practicable measures for the relief 
of this anomaly in its earliest incipiency. 2 

1 What about Rotch's methods, or Holt's? — Editor. 

* The muscular incompetency depending on early rachitis and resulting in and after 
the third month of life has not been mentioned. It is a frequent occurrence, and re- 
quires antirachitical treatment. — Editor. 



196 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 



CHRONIC DIGESTIVE DISTURBANCES OF BOTTLE-FED INFANTS 

In regard to the prognosis these maladies are in coarse contrast to the 
various affections of breast-fed infants. A chapter in the pathology of nurs- 
lings is here unfolded which, as regards the etiology and pathogenesis, is one 
of the most obscure in the investigation of diseases of childhood, and as to the 
results obtained by therapeutics requires the most strenuous efforts of even 
the experienced pediatrist. 

In the chronic digestive disturbances of artificially-fed infants we find 
all of those anomalies of the fecal movements which we have learned, from 
the pathology of the acute gastro-intestinal affections of infancy, to recognize 
as dyspepsia, intestinal catarrh, and enteritis. Here, however, as in the other 
chronic diseases, the acute, tumultuous onset of the process is lacking and 
the various forms are not sharply defined, losing their characteristic type 
and merging into or alternating with one another. 

"Simple" chronic intestinal disease of the artificially-fed infant, which 
occurs in association with an acute affection, should be separated from the 
"severe" type, the termination of which, under the picture of extreme emaci- 
ation, we recognize as atrophy ( pedatrophia or athrepsia, Parrot). This clini- 
cal picture, to which the English give the name marasmus, was formerly, 
through a false conception, described under the name tabes mesenterica. A 
sharp distinction of the two pathologic processes is not intended by this divi- 
sion for often enough the gradually declining processes occurring in connec- 
tion with acute digestive disturbances of nurslings present the typical picture 
of atrophy. But even more frequently is the complete picture of atrophy as 
a disease sui generis developed without preceding alarming disturbances on 
the part of the intestine. 



SIMPLE CHRONIC INTESTINAL DISTURBANCES OF ARTIFICIALLY-FED INFANTS 

As a rule these originate from an acute intestinal or gastric catarrh. The 
abrupt symptoms, the fever, and the diarrhea subside in the course of a few 
days and with this an apparently mild subacute disturbance appears without 
especially prominent phenomena on the part of the digestive apparatus. In 
other instances the affection develops more insidiouslv, with less obvious 
symptoms. Slightly altered dyspeptic feces of greenish yellow or green ap- 
pearance, or a gray or grayish yellow and occasionally dry stool, introduces 
the disease. In other instances there is a more marked involvement of the 
small intestine, as is evident from the fluid evacuations, or an affection of the 
colon is indicated by an admixture of mucus, blood and pus. Quite often a 
varying picture is observed: the dyspeptic and catarrhal symptoms alternate, 
always, however, in apparently mild form and slight intensity. 

Vomiting is now and then noted at the onset, the milk being regurgitated 
in small or large masses soon after its ingestion. In the further course of 



CHRONIC DIGESTIVE DISTURBANCES OF BOTTLE-FED INFANTS 197 

the malady this symptom is more rare, only occasional small, clumpy, coagu- 
lated, very acid masses being ejected from the stomach. In many infants 
symptoms on the part of the stomach are lacking. 

Microscopic examination of the feces shows nothing characteristic of 
chronic catarrh. The chemical analysis of the gastric contents shows in 
almost all cases a decreased hydrochloric acid secretion. 

The constitutional condition of the child appears to be but little disturbed. 
Fever is commonly absent, but it may appear intercurrent^ with a lapse of 
dietetic stringency or from complicating purulent or septic processes. 

Colic is uncommon although after the ingestion of food there is at times 
a decided restlessness. As a rule the abdomen is not distended nor tense but 
rather pliable; as the affection progresses, however, there is retraction and 
the abdominal coverings are depleted of fat and become so thin that the 
internal organs and the mesenteric glands are readily palpable. 

The disposition of the child, at first but little influenced, eventually 
changes to fretfulness and whining. The smiles which are common in health 
and are such a source of happiness to the mother, become rare and at last 
disappear altogether from the face of the ailing child. In the course of time 
the complexion becomes pallid, the expression languid and suffering, although 
the eyes are bright and clear in contrast to the furrowed and aged features. 

The appetite is often poor or entirely lacking; occasionally it appears to 
be increased since the child drinks eagerly from the bottle, but the food is 
frequently soon vomited. 

The tongue is usually coated; in the further course of the disease it is 
often glistening red and simultaneously the entire mucous membrane of 
the mouth is intensely inflamed, sometimes thickly covered with thrush or 
merely with isolated aphthous loss of substance. Salivation may be increased 
or lessened. The odor from the mouth is fetid or slightly putrid. 

The amount of urine is somewhat decreased and almost always contains 
sediment and often albumin. 

While at first the arrest or even the loss in weight is scarcely obvious, 
especially if weighing at regular intervals is not practised, in the further 
course of the disease and perhaps in a short time the emaciation of the entire 
body becomes apparent and is particularly conspicuous in the face and extremi- 
ties. The skin and muscles lose their fat, producing loose folds which lend to 
the entire body a withered appearance and to the face an aged expression. 
The abdominal skin becomes thin and flaccid and, owing to the loss of its 
elastic tension, forms into folds. 

These symptoms gradually attain greater prominence, the emaciation 
becomes more conspicuous and impresses its characteristic stamp upon the 
infant. 

The weight sometimes declines slowly, at other times rapidly, but the 
decline is not necessarily continuous; on the contrary, there is occasionally 
a period of apparent improvement with a transitory moderate gain in weight, 
which in time is succeeded by a loss. Thus, according to its gravity, the con- 



198 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

(lit ion may continue for weeks or months, and even then, with suitable treat- 
ment, may terminate in recovery. 

In other cases of protracted course the child gradually loses strength and 
finally perishes with the manifestations of cerebral anemia, cardiac collapse, 
or in an eclamptic seizure. Convulsions are extremely common in the termi- 
nal stage of the affection. A portion of the children succumb to a renewed 
acute intestinal disturbance — intestinal catarrh, enteritis — or with the toxic 
symptoms of cholera infantum. The remainder of the patients pass into the 
lingering invalidism of atrophy. 

The most frequent complications of chronic intestinal catarrh in bottle- 
fed infants are intercurrent acute gastric or intestinal disturbances; now and 
then severe vomiting. In addition the skin and the mucous membranes, on 
account of their decreased resistance, provide excellent points for the entrance 
and colonization of microorganisms of the most various kinds which give 
rise to diseases of the skin, such as ecthyma and furunculosis, and upon the 
mucous membrane of the mouth to thrush and other forms of stomatitis. 
Otitis media is not an uncommon complication. Frequent eclamptic attacks, 
diseases of the bronchi and of the lungs, inflammatory conditions of the bladder 
and of the kidney, render the prognosis serious and in many cases endanger life. 

Besides the atrophic conditions which we have learned to recognize as 
the frequent termination of a chronic intestinal catarrh there is a picture of 

ATROPHY 

of more typical form and in its highest ascendency, which we are disposed 
to regard as genuine atrophy, as a disease sui generis. 

By this genuine atrophy, therefore, we understand a chronic nutritive dis- 
turbance of artificially-nourished infants which is characterized by a con- 
stantly increasing atrophy of the muscles and of the fatty tissue, and which 
finally leads to a permanent arrest or continuous loss of weight and to extreme 
emaciation. 

In this consideration of primary atrophy all of those secondary atrophies 
are excluded which are accompaniments of tuberculosis or syphilis or are the 
consequence of severe acute lesions of the digestive tract and of exhausting 
diseases. 

The so-called " hunger atrophies " of breast-fed infants are also omitted 
which have already been described and which, as a rule, owe their origin to 
insufficient food from a breast that secretes an inadequate quantity of milk 
without the knowledge of the inexperienced mother. Nor in the description 
of this special nutritive disturbance shall we discuss the conditions of hunger 
and death from starvation, such as are brought about artificially in the so- 
called baby farms ("Engelmacherinnen") by means of hunger cures or the 
gradual withdrawal of food. We shall limit ourselves to the genuine atrophy 
which arises with an apparently rational and adequate nourishment and in 
fact appears mysteriously without gross digestive disturbance, I might almost 
say without a demonstrable cause. 



CHRONIC DIGESTIVE DISTURBANCES OF BOTTLE-FED INFANTS 199 

The development of the affection is very gradual. Children previously 
in apparent health and developing normally gradually become pallid and 
feeble. The increase in weight is no longer satisfactory or an arrest has 
occurred. Very slowly and unsuspectingly the phenomena of emaciation and 
its consequences become obvious. 

The pallor increases, the infant appears completely emaciated; the upper 
and lower extremities are flaccid and wasted, skin alone covers the chest 
and back so that every individual rib is outlined. The bones of the skull 
overlap, the fontanelles are often depressed. The face shows numerous folds, 
especially upon the forehead; the bones of the face project, the temporal 
region is depressed, the cheeks are hollow, there are sharp lines about the 
nose and mouth; the nose stands out prominently. All of these phenomena 
convey to the infantile countenance the physiognomy of senility. The pic- 
ture develops with the progressive disappearance of fat and constantly increas- 
ing emaciation and loss in weight. 

The expression of the child is care-worn, with deeply sunken but clear 
eyes. The disposition is altered, the patient is fretful and whining. The 
voice becomes hoarse. 

Sleep is restless, often light and disturbed. Providing no inflammatory 
complication is present the temperature is normal or frequently subnormal. 

The digestive function of the little patient in many instances is undis- 
turbed. The appetite is usually good, sometimes even increased; the fluid 
requirement appears to be very great and even qualitatively the child demands 
more than the normal infant. It often grasps the bottle hastily and when 
tormented by hunger empties it rapidly. In the intervals between the feed- 
ings the child forces its fist into its mouth, presenting the picture of insatiable 
greed. 

The fecal evacuations, in many instances, are perfectly normal, in others 
there is an intercurrent, very transitory dyspeptic or catarrhal condition, and 
more rarely normal periods alternate with mild or severe intestinal dis- 
turbance. 

With the symptoms above described the child emaciates more and more 
until it appears almost a skeleton. The adipose tissue and the muscles of 
the entire body have disappeared until nothing but skin and bones remains. 
The skin, as a covering for the tissues in and around it, has become too loose 
and " hangs " from the bones. 

Ohlmiiller has shown by an analysis of a normal and an atrophic infant 
of the same age that the decrease of weight in atrophy is to be ascribed 
principally to the loss of the fatty tissue. In the case examined by this 
author, in which 57 per cent, of the total weight had disappeared, 90.9 per 
cent, of the fat supposed to have existed in the body previously and 30.7 
per cent, of the albumin substances were lacking. The loss of solid con- 
stituents from the heart, the liver, the brain, and the bones was much less 
than that from the muscles, the skin and the intestines. 

The face has the appearance of senility; the skin and the mucous mem- 



200 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

branes very often reveal inflammatory conditions (aphthous and other forms 
of stomatitis, intertrigo, ecthyma, furunculosis). The same diseases which 
arise as complications in the simple, chronic, intestinal disturbances are also 
common here. Aside from eclamptic and tetanic conditions, which are espe- 
cially frequent sub finem but which may often develop no further than a 
slight spasmodic muscular tension in the extremities and in the nape of the 
neck or simply an increased restlessness which is sometimes alternated with 
apathy, processes of especially purulent and septic nature are noted, as affec- 
tions of the intestine, lungs, bladder, kidney, and brain, which are either 
a transitorv menace to the infant or are the termination of the tragedy. 
During the last hours prior to death there is occasionally, as in other severe 
conditions of intoxication, an irregular, rapid and deep respiration (acid 
respiration, Czerny). 

Under this picture of distressful misery the infant in extreme cases sinks 
deeper and deeper in consequence of the unabated and disastrous loss of weight, 
and ultimately perishes with the signs of hyposthenia but without special symp- 
toms of disease. 

In regard to the course and termination of "genuine" atrophy there can 
be no doubt that the prognosis for infants treated in the hospital is more 
unfavorable than for those of private practice. Of the various points which 
demonstrate this seemingly contradictory statement it must be remarked 
that in all probability in hospitals the monotony and errors in nursing are 
not so much at fault as the possible action of infectious toxins (toxin pro- 
ducers) which have accumulated in the wards of the hospital and in some 
manner find entrance to the organism, causing an inhibition of the normal 
development and consequent emaciation. In private practice these influences 
(hospitalism), of which the latter even in the hospital is operative only 
periodically and transitorily, are usually absent, and therefore the chance of 
recovery is very much more favorable. Even in the the hospital, however, 
a cure of the atrophic condition is possible and in fact is often observed; it 
is true that at certain times our curative endeavors find a more favorable 
soil than at others, and from clinical observation the impression is gained 
that the miasmatic agent which terminates severe marasmus comes and goes 
in the hospital, or at all events is not permanently present. 

In regard to the course of " genuine " atrophy all possible variations may 
be considered. Apart from the complications that have been mentioned, only 
the degree of emaciation and the amount of weight lost or the length of time 
the weight is arrested furnishes an indication as to whether the affection must 
be regarded as hopeless or whether we are to encourage the parents. But in 
the decision of these two factors even the experienced physician is frequently 
in doubt, since, after a hopeless condition of invalidism, an almost unaccount- 
able improvement may be observed just as frequently as a sudden catastrophe 
after days of apparent betterment. 

Thus, cases will be observed which speedily terminate in recovery after 
brief treatment. In other patients there is a slow gain in weight which in 



CHRONIC DIGESTIVE DISTURBANCES OF BOTTLE-FED INFANTS 201 



Grams 
6500 

6300 
6100 
5900 
700 
500 
300 
5100 
900 
700 
500 
4300 


































































































































































































































































































11 12 

14 Food 

with 
Pegnin. 


13 11 

% Food 
with 

Pegnin. 


15 16 17 18 

Full Milk 

with 

Pegnin. 


Week 



Fig. 4.— P. G., aged 11. Undiluted milk with 
pegnin. Vomiting and arrest of weight. Diag- 
nosis: ATROPHY. 



turn declines and rises again, and 
after numerous alternations falls 
rapidly and the affection termi- 
nates fatally. Or after several in- 
creases with succeeding " catas- 
trophies," as Heubner calls this 
repeated rise and fall, the resist- 
ance of the organism finally gains 
the victory and the process termi- 
nates in recovery. Again, for 
weeks or months there may be 
only a slight gain or loss, the 
weight curve showing an almost 
straight line, but eventually, 
through decrease in strength or 
the appearance of some complica- 
tion, death takes place, or in- 
versely, by a sudden increase of 
weight, improvement and com- 
plete recovery result. 

This peculiar symptom-com- 
plex, which is here demonstrated 
by the weight curves (Figs. 4-10) 

offers the greatest difficulty in regard to its etiology. At least it is impossible 
at the present time to form a clear and complete picture of the processes which 

are operative i n these 
chronic, nutritive d i s - 
turbances in the infantile 
organism and especially 
in the metabolism. It 
must be admitted that 'in 
some of the cases chronic 
digestive debility pro- 
duced by hypernutrition 
or improper feeding is a 
predisposing factor, o r 
that an occasional, tran- 
sitory, chronic, trivial, 
d i g e s t ive disturbance 
plays an etiologic role in 
the introduction of the 
process. 

It would seem obvi- 
ous that in a disease run- 
ning its course with such 







Grams 

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Malt Soup 
Extract. 


16 17 18 19 Week 



Fig. 5. — E. H., aged eight weeks. Keller's malt soup. Atrophy. 



202 



CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 



a conspicuous loss of fat of the skin, of the muscles, and of the internal organs 
we should seek the explanation in a severe lesion of the intestine, as the secre- 
tory and resorptive apparatus. As a matter of fact this theory has been 
invoked by some investigators to explain this peculiar chronic anomaly. 

The main exponent of this view is Baginsky, who even to-day maintains 
that "atrophy is the consequence of disturbed assimilation arising from 
atrophic alteration of the intestine." In support of this view he offers two 
important points ; first, the severe atrophic and degenerative anatomical lesion 
of the intestinal tract as regards its epithelium and its glands, and second, 

the enormously decreased resorp- 
tion of the important constituents 
of the food. 

In the post-mortem examina- 
tion of the mucous membrane of 
the intestine of infants who had 
succumbed to atrophy Baginsky 
found various conditions ranging 
from a primary inflammatory ir- 
ritation with infiltration of the 
mucosa to chronic inflammatory 
swelling and proliferation of the 
villi, glandular structures, and 
follicles. These severe changes of 
hyperplastic nature in the glands 
and villi are succeeded by desqua- 
mation of the proliferated and 
loosened tissue and finally by a 
destruction and atrophy of t h e 
surface of the intestine. 

Although the enigma of atro- 
phy in infants is best solved upon 
the basis of an anatomical lesion 
there are so many considerations based on other post-mortem findings (Heub- 
ner, Habel, Finkelstein, Fehde, Bloch, E. Meyer) which are opposed to this 
view of Baginsky's that we cannot agree with him. A number of cases of un- 
questionably genuine atrophy are reported in which minute investigation of 
the contracted intestine has shown that all the glands and villi are well formed, 
Lieberkiihn's follicles pressed close together and covered with epithelium, and 
which exclude any gross lesion of the intestinal mucous membrane and of the 
remaining intestinal wall in all of its parts. The lesions described by some 
authors as those of intestinal atrophy may be produced by inflation in any nor- 
mal bowel, in fresh as well as in decomposed intestines. So-called spontaneous 
intestinal atrophy has never been found in contracted intestines. Therefore 
we must conclude that the lesions which are supposed to indicate atrophy may 
be referred to an altered physical condition of the intestinal wall ; in this case 



Grams 

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700 
500 
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Fig. 6. — A. R., aged six weeks, a twin. Atrophy. 



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Fig. 7. — F. D., born December 9, 1902. Weight 3600 grams. Brought for treatment July 7, 
1903, "because it does not gain in weight." Constipation; cries much; occasional vomiting. 
Food, one-third milk, later ramogen. Never developed properly. Treatment with pegnin 
added to one-third milk. 

Weight at beginning of treatment 3600 grams 

at twenty-seven weeks 4800 " — normal 7500 grams 
Gain 1200 " 

Gain per week 40 " 

203 



204 



CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 



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the anatomical proof of a true 
atrophy of the mucous mem- 
brane in general atrophy of 
nurslings cannot b e demon- 
strated and the entire theory 
founded upon this teaching is 
untenable (Heubner). How- 
ever, I do not pretend to doubt 
the fact that, like the other tis- 
sues, the intestine of the shriv- 
elled child is atrophied, i. e., 
emaciated, as has been proven 
by Ohlmiiller's investigations 
previously quoted. 

A severe anatomical lesion 
of the mucous membrane of 
the intestine would not coin- 
cide with the clinical facts, 
since we have seen from the 
course of the affection that oc- 
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validism the entire picture 
suddenly changes, improve- 
ment takes place, and finally 
recovery. 

In a severe anatomical de- 
fect of the mucous membrane 
repair in so brief a time can- 
not be considered. Baginsky 
explains these sudden improve- 
ments by the fact that in addi- 
tion to the more or less altered 
or completely destroyed areas 
of the intestine there are also 
quite normal portions which 
are intact and covered with 
well-retained epithelium. 

In spite of the lack of 
proof of atrophy of absorbing 
intestinal epithelium it cannot 
be denied that in some cases, 
in so far as assimilative inves- 
tigations in atrophic infants 
are at hand, the power of 
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206 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

suffered. Baginsky found, in three cases where the intake and output of 
the N-containing bodies had been determined, that in the first case the N-loss 
was 52.7 per cent., in the second 37 per cent., and in the third 45.2 per 
cent., in contrast to the normal N-absorption which, according to the inves- 
tigations of Forster, Uffelmann, Camerer, Lange, and Bendix, amount to 
80-96 per cent. 

Heubner also saw two cases of genuine atrophy in infants with skeleton- 
like emaciation in which the absorptive power of the intestine was so de- 
creased that in one instance 43.7 per cent, and in the other 54 per cent, of 
the introduced nitrogen was unabsorbed. 

From my own investigations, with the exception of the case observed with 
Heubner, it appears that with a rational feeding a decrease of nitrogen assimi- 
lation does not exist in the atrophic child to any marked extent, as I have 
found values for the absorption of nitrogen of 71.96 to 85 per cent. 

In a review of the literature regarding metabolism of atrophic nurslings 
the figures for the resorption of nitrogen are 86-95 per cent. (Freund) and 
81-95 per cent. (Keller) ; Lange also reports similar figures. 

In contrast to this slight loss in nitrogen (except in Baginsky's and 
Heubner's cases) I was enabled to determine one fact in my investigations 
of the metabolism in atrophic infants, namely, a decided reduction in the 
absorption of fat. In some instances the loss amounted to 40-50 per cent. 

Although the decreased power of absorption certainly plays an important 
part in the deficient gain in weight or in the progressive deterioration of the 
health of the atrophic infant this does not entirely explain the resulting 
atrophy, as in some instances, with a fair intake of nitrogen and in spite of 
greatly reduced fat absorption, sufficient heat units are taken up and even 
more than are necessary, according to our present views, for the energy 
requirement of the infant — for the functional activities as well as for an 
increase in weight. 

At the present time we calculate the " energy quotient " = the number 
of heat units for any given weight of the body, as 100 calories per kilo per 
day for the normal infant. In one of my experiments an atrophic child was 
given 125 calories per day and per kilo. If, however, in addition to the 
decreased absorption of food there is an increased expenditure of energy, 
which is principally lost through digestive function and by destruction of 
the cells, as may be recognized by an abnormal increase, in the interchange 
of gases, there would be in these two components together a better expla- 
nation for the atrophic condition. 

Heubner has illustrated the disproportion in the atrophic infant between 
the intake of energy and the energy loss by a simple equation with the symbols 
first utilized by Camerer. If n = energy of the food, e = energy of heat 
radiation and of evaporated water, I = energy of substance given off from 
the body, v = loss in absorption, it is clear that when e + I + v becomes 
greater than n, a becomes negative, i. e., loss in weight must take place. 

With an appreciation of these relations of metabolism it would be clear 



CHRONIC DIGESTIVE DISTURBANCES OF BOTTLE-FED INFANTS 207 

why the weight of the child is arrested or even diminished, but it does not 
explain how the atrophic infant acquires this peculiar debility of digestion 
and why, in the metabolism of its nutritive material especially, a far greater 
labor is required than under normal circustances. In addition there must 
be explained the accompanying phenomena of atrophy of the skin, the mucous 
membrane, the kidneys, and the nervous system, which have already been 
explicitly detailed. 

In explanation of such changes it has been thought that these compli- 
cations, like the deleterious atrophic conditions in general, may be referred 
to intoxications which have arisen from the destruction produced in the 
intestinal tract by saprophytic or specific bacteria. 

In addition to chronic poisoning by infectious toxins a disorganization 
of the constructive material, as Finkelstein believes, may also arise from auto- 
intoxication, since, either in the intestine or in the intermediary metabolism, 
deleterious products of a non-infectious variety are formed or substances 
which are normally unabsorbable are assimilated. To the present time all 
attempts to demonstrate such toxins have failed; neither from the contents 
of the intestine nor from the intestinal wall has it been possible, at least in 
the animal experiment, to obtain substances which could be proven to be 
toxic, either by feeding, by intraperitoneal injection or by inoculation into 
the blood current. 

As an explanation of the atrophy of infants Czerny has given a definite 
form and conception to the idea of an intoxication of the organism. He 
regards this disease as a chronic nutritive disturbance produced by an acid 
intoxication from hyperacidity of the organism (acidosis) which necessitates 
a greater activity, to which it is unequal on account of the toxic effect of the 
circulating acids. According to Czerny the details of this acid intoxication 
are as follows: Through improper feeding and especially through a surfeit 
of food, acids arise in the decomposition of albumin products and in the split- 
ting of fats, which act upon the organism as poisons even when no toxins 
or harmful bacteria are introduced into the intestinal tract. In this process 
milk sugar is of less consideration because of its high assimilative limits. 
Czerny concludes, however, that the acid intoxication not only has the im- 
portance for the organism of making nourishment difficult or even impossible, 
but that also by the continued decrease of alkalinity an essential part of 
those properties is lost which protect the organism from infection. In the 
former condition a food which contains normal amounts of albumin and fat, 
well borne by healthy children, produces threatening symptoms of intoxica- 
tion; a deficit of albumin necessitates the consumption of the child's body 
albumin and causes a rapid decline in weight. In the latter ease, infants 
suffering from acid intoxication may develop secondary infections from the 
intestine and in consequence the clinical pictures which at first are quite 
similar, may in their further development be extremely diverse. Thus there 
is a permanent vicious circle dependent upon the intake of food and, resulting 
from this, acid intoxication, insufficiency of function, and disturbed nutrition. 



208 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

This theory, propounded by Czerny in 1897 upon the basis of clinical 
facts, and at that time but little credited, has by the incessant labor and 
painstaking investigation of this author and his pupils (Keller, Freund, 
Thiemich, v. d. Berghs, Steinitz) developed from a firm foundation into a 
stately structure, but does not furnish an absolutely reliable explanation for 
all cases and under all circumstances. The actual outcome of Czerny's theory 
of acid intoxication is Keller's important finding of an increased excretion 
of ammonia through the kidneys in 10 out of 11 infants with chronic intes- 
tinal disease. Because of the amount of ammonia found in normal adults 
and of the findings in the healthy new-born, the Breslau school came to the 
conclusion that the absolute and relative increase of ammonia observed in 
the urine of infants with chronic gastro-intestinal disease represented a dis- 
turbance of the intermediary metabolism. An explanation of the increased 
excretion of ammonia when acids circulate in the body is given by the fol- 
lowing chemical process: If there is an excess of acid in the organism and 
the quantity of fixed alkali present is insufficient for its neutralization, am- 
monia takes its place, is absorbed by the acids for the formation of salts for 
excretion, and is passed with the urine even before its further reduction 
into salts of ammonia. The excretion of ammonia is relatively greater, that 
of urea less, than normal. 

That the increased excretion of ammonia in the urine, determined by 
Keller, does not depend upon a disturbance of the hepatic function which 
produces urea but upon an excessive production or decreased oxidation of 
acid products of metabolism is obvious from the investigations of v. d. Berghs, 
according to which, after the administration of alkalies ( Schroder-Miinzer's 
criterion) a combination of acids, a transformation of ammonia into urea 
and its excretion as such, takes place as under normal conditions. 

As fascinating as is Czerny's theory of acid autointoxication, nevertheless 
quite a number of links in the chain of evidence are lacking which we are 
accustomed to require in the well-known adult types of acid intoxication 
(diabetes, carcinoma, leukemia, etc.) and which have been demonstrated 
in these maladies. Among them are the decrease in the alkalinity of the 
blood, increased acidity of the urine, with the demonstration of physiologic 
acids in increased amounts or of pathologic acids of various kinds in the urine. 

After the failure to demonstrate these points it must be assumed, as 
Pfaundler quite properly asserts, that in chronic gastro-intestinal disease of 
nurslings, if an acid autointoxication is present at all it cannot be such as 
is ordinarily implied and with which we are familiar in the pathology of 
adults. 

To these deviations from our ordinary conception of acid autointoxication 
a few factors must be added which are calculated to raise a doubt as to whether 
the explanations of the Czerny school for the chronic nutritive disturbances 
of infancy are conclusive or absolutely reliable. It has been shown that high 
ammonia values are occasionally present in normal nurslings (Pfaundler) 
and it is also positive that they are not invariably present in nurslings with 



TREATMENT OF CHRONIC DIGESTIVE DISTURBANCES 209 

chronic intestinal affection — a fact which I was the first to prove by positive 
investigation, and which was later confirmed by Pfaundler. 

A further especially important fact which I demonstrated in my experi- 
ments of 1898 is that the co-efficient of ammonia — as Pfaundler terms the 
percentage of nitrogen excreted in the form of ammonia, compared with the 
total amount of nitrogen — depends upon the quantity of fat in the food. 
This fact is confirmed by Keller's findings, which prove that the high excre- 
tion of ammonia is made greater by the administration of milk rich in fat, 
or of cream, but which falls to normal as soon as milk containing but a 
moderate amount of cream or even deficient in cream is administered. 

In view of these relations the question of autointoxication appears in 
quite a different light. Strictly speaking, we should not even refer to an 
autointoxication, as Pfaundler has declared in a recent critical review of 
this question, as we are dealing with an external effect through the composi- 
tion of the food, which does not present a demonstrable deleterious influence 
as the immediate consequence, but, on the contrary, an " alimentary hyper- 
acidity " or a " fat-feeding acidosis " (Pfaundler) . 

As, however, infants with normal digestive function react to an increased 
administration of fat in the same manner as patients with gastro-intestinal 
disease — according to Pfaundler, by an increase in the ammonia co-efficient — 
it cannot be said that an increased excretion of ammonia in the urine is a 
positive criterion of a chronic nutritive disturbance of nurslings. 

In addition to the high amount of fat in the food of infants, which pro- 
duces an alimentary acidosis in both the healthy and sick, the high renal 
excretion of ammonia may also be due in part to a certain lack of oxidating 
activity, or, in children suffering from chronic gastro-intestinal disease, even 
a degeneration of the hepatic tissue may be held responsible (Pfaundler, 
Bruning). 

Therefore, after all the theories that have been invoked to explain the 
chronic digestive disturbances of infancy, the symptom-complex which we 
have designated atrophy or athrepsia still remains unsolved. However, that 
atrophy is in relationship with and dependent upon the nature of the nourish- 
ment may be regarded as certain since it accords with experimental findings 
and clinical facts. That improper food is not infrequently the starting-point 
of this serious disturbance is undoubted, and just as true is the observation 
that by the administration of " correct " food the severely damaged general 
condition may be improved and the affection brought to a favorable termi- 
nation. 

TREATMENT OF CHRONIC DIGESTIVE DISTURBANCES 

In the treatment of the chronic digestive disturbances of infancy it will 
be necessary, in evolving a plan of cure, to differentiate between the " simple " 
chronic affections, which arise in conjunction with acute maladies, with chronic 
dyspeptic or catarrhal fecal discharges and simultaneous feebleness and 
emaciation of the infant, and " genuine " atrophy. 
15 



210 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

For both forms the general rule may be advanced that the best and most 
curative agent is breast-milk wherever there is a possibility of its adminis- 
tration. In carrying out this plan of treatment, however, insurmountable 
difficulties may arise. The child who has already cut its teeth bites the 
nipple while nursing, the breast becomes sore, and this injury and the result- 
ing pain necessitate weaning. In other instances the debility of the infant 
prevents the withdrawal of the required quantity of milk. The aid of the 
milk-pump for this purpose fails because the amount of milk obtained is 
too small and the gland is not emptied sufficiently, in consequence of which 
a stasis arises which in itself affects the quality of the milk and gradually 
leads to an arrest of the secretion. Therefore, while in all cases of intestinal 
disturbance which arise in artificial nutrition it is advantageous to advise 
natural food, nevertheless, on account of the difficulties that have been men- 
tioned the attempts in this direction will in some instances be fruitless. 

If natural food for one or another reason is impracticable, artificial 
nourishment must necessarily be employed. In adopting this plan I believe 
it to be important, as in the treatment of acute digestive disturbances, to 
cleanse the digestive tract and to institute a hunger or rest diet for the 
intestine to determine the measure of the intestinal secretory and absorptive 
activity after this period of rest. Therefore, in treating an infant with 
chronic intestinal disease or with atrophy, the following is the method of 
procedure : 

A single gastric lavage, repeated perhaps if there be continued vomiting. 
The evacuation of the stomach contents may at the same time serve for 
estimating its acidity. A mild laxative to empty the intestine; I prefer four 
doses of 0.03 grams each of calomel at intervals of three hours. The effect 
of the remedy is shown by a green discoloration of the feces. Instead of this 
a teaspoonful of castor oil may be given three or four times during the day. 
After the lavage of the stomach food should be withheld for five or six hours. 
This is followed by the so-called hunger cure. For this purpose we utilize 
either dilute decoctions of tea with the addition of sugar or saccharin, or simply 
boiled sweetened water, perhaps with the addition of ten to twenty drops 
of brandy to every bottle when debility is present. This hunger cure should 
be continued for at least twelve hours. The intervals between the individual 
feedings should amount to at least three and one-half hours; the quantity 
may be somewhat larger than under normal circumstances (150-200 grams). 
Upon the hunger days the stool is scant, and with a previous catarrhal or 
dyspeptic condition it may be regarded as a favorable sign of the activity 
of the intestine if the fecal mass is formed. 

This hunger diet is to be succeeded by a period of rest or forbearance 
for the bowel amounting to forty-eight hours. For this purpose the child 
is given a decoction of the "simple" starches. By these we understand 
barley, oats, wheat flour, mondamin, arrow-root, tapioca, etc., not the manu- 
factured or milk flours which consist of a mixture of milk with some form 
of flour and in which the starch by some process has been changed into 



TREATMENT OF CHRONIC DIGESTIVE DISTURBANCES 211 

dextrin. These flour mixtures are to be quite thick, 8-10 per cent. : A 
tablespoonful and a half of flour is mixed with 1/2 liter of water, to which 
1 1/2 teaspoonfuls of sugar are added while the mixture is constantly stirred. 
After boiling for fifteen minutes the quantity for one feeding is ready. 

If, after this rest-diet, there is a homogeneous grayish-yellow starchy 
stool, free of mucus and other abnormal constituents, instead of the greenish, 
chopped, thin or mucus stool, we cautiously proceed to milk food by gradually 
reducing the quantity of starch and increasing the quantity of milk, its 
amount and composition to be governed by the age and weight of the child, 
and its administration to be at first in small amounts and at long intervals. 
It is best to begin with 1/3-food (350 grams milk, 650 grams mucilaginous 
material, 52 grams sugar), gradually increasing to 1/2-food (500 grams 
mucilaginous material, 50 grams sugar), and finally employing more concen- 
trated solutions. In addition to observing the activity of the intestine the 
nutritive requirement of the infant must constantly be kept in mind. If we 
remember that the energy quotient of the normal nursling equals 100 we 
will often note that an infant with chronic intestinal disease, especially at 
the beginning of the treatment, often requires a much greater supply of food 
(120, 150 or even 170 calories) to gain in weight. 

If the abnormal fecal discharges of infants suffering from chronic dys- 
pepsia do not disappear after a course of the rest-diet and when the milk 
nourishment has been carefully conducted, in my opinion an infant food 
might be employed with advantage. Which of these is to be given, whether 
Nestle's, Neave's, Eademann's, Rademacher's, Theinhart's, Kufeke's, is quite 
immaterial, as they are all manufactured on the principle that in their chemi- 
cal composition they should as closely as possible resemble breast-milk. 

These infant foods are usually administered in a 5 per cent, decoction, 
200 to 250 calories being given per liter. 

If improvement of the condition is not brought about by these foods 
then all of the milk substitutes are to be tried with which modern chemistry 
of the last decades has supplied us. 

The most important and useful of these, from which good results are 
sometimes obtained, may be arranged, according to definite principles, in 
the following order (compare B. Bendix, Milk Substitutes, in Eulenberg's 
Encyclopedic Year-books, IX, 1900, p. 249) : 

Group I : Milk with Decreased Amount of Albumin, Addition of Fat. 

1. Biedert's cream mixture (natural, artificial) — see ramogen. 

2. Gartner's fat-milk. 

3. Lahmann's vegetable milk (principle of a cream mixture with vegetable 

albumin and fat in addition to the milk). 

4. Condensed (Swiss) milk. 

Group II : Diluted Milk Enriched with Fat, the Albumin of which 
is Predigested and More or Less in Solution. 
1. Backhaus' milk (addition of cream, solution of part oi the casein by 
trypsin). 



212 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

2. Voltmer's mother's milk (conversion of cow's milk by the addition of 

pancreas ferment into pepton ; otherwise the composition analogous 
to human milk). 

3. v. Dungern's lab-milk (addition of a pinch of " pegnin " to 200 grams 

of undiluted milk). 

Group III: Decrease of the Amount of Albumin by Dilution; In- 
crease of Fat; Soluble Albuminates of Peptons as a Substi- 
tute for the Deficit in Albumin. 

1. Rieth's albumose milk (substitution of the casein by a non-coagulable 

albumose prepared from egg albumin by heating) ; addition of 
cream and sugar. Similar to Hartmann's somatose milk. 

2. Hampel-Lehmann's milk (dilution of cow's milk so that the casein 

amounts to 0.75 per cent., addition of the yolk of one egg (phos- 
phorus -\- iron) and the white of one egg. Enrichment with fat 
and the addition of milk sugar produce a nutritive mixture which 
in its quantitative composition resembles human milk). 

Group IV: Mixtures Deficient in Fat but Rich in Sugar (Especially 
Malt Sugar). 

1. Liebig's soup (diastasic action of the flour from malt). 

2. Keller's malt soup (50 grams wheat flour -f- 650 water, 100 grams Lof- 

lund's malt-soup extract -f- 350 milk). 

3. Allenbury's infant food No. Ill (malted food). 

4. Liebe's neutral food (Dresden). 

5. Soxhlet's nutritive sugar. 

6. Brunnengraber's malt powder (Rostock). 

Group V : Buttermilk. 

Group VI : 

v. Mering's " Odda." Carbohydrate dissolved in part by diastasic 
action and opened by the baking process, mineral products consist- 
ing of % phosphoric acid and % calcium oxide, instead of the fat 
of butter, the fat of an egg-yolk with lecithin and vitellin, and 
cacao butter. 

Although, as may be noted from their composition, in these substitutes 
a definite principle has always been maintained, so that by the addition of 
ferments the labor of digestion is facilitated or some nutritive product is 
decreased in favor of another, nevertheless it is quite difficult to establish a 
strict indication as to which disease or under what circumstances any of these 
nutritive remedies is applicable. Only in two conditions does practical expe- 
rience serve as an indication. If there be a decrease of hydrochloric acid 
secretion and if the infant with chronic gastro-intestinal disturbance suffers 
from frequent vomiting excellent results are often observed from Backhaus's 
milk, albumose milk, buttermilk, or Dungern's lab-milk. In administering 



TREATMENT OF CHRONIC DIGESTIVE DISTURBANCES 213 

these modifications, therefore when introducing either predigested or easily 
absorbed albumin into the food, or perhaps in employing ferments, we facili- 
tate the digestive labor and stimulate the epithelium to a greater activity, 
wherewith in fact the proper indication is met. 

In a second series of cases, those with chronic fatty diarrhea, we also 
know which substitutes are most useful. Practical experience teaches that 
here only mixtures deficient in fat should be employed ; accordingly Backhaus's 
milk No. 1, skimmed milk, and buttermilk should be used. In addition infant 
foods may be given. 

In the majority of instances, however, we have practically no indication 
as to which of the substitutes are to be employed. Often enough the various 
foods must be tested successively until one has been found which causes the 
intestinal disturbance to cease and the child to gain weight. One point, 
however, may be definitely maintained from clinical experience at the bed- 
side: Mixtures rich in fat, such as Biedert's ramogen and Gartner's fat- 
milk may be used only with the greatest caution in chronic intestinal 
disturbances; inversely, nutritive solutions deficient in fat, such as Liebig's 
soup, Keller's malt soup and buttermilk very frequently bring about good 
results. Particularly in genuine atrophy do the alkaline soups, deficient in 
fat but rich in malt sugar, occupy a prominent place in therapy. Among 
these we include : 

1. liebig's soup. 

This is prepared as follows: One hundred grams of wheat flour are 
mixed with one liter of milk, which is stirred in gradually to prevent lumping. 
This mixture is kept three or four minutes at the boiling-point and is then 
removed from the fire. Into another vessel 100 grams of malt flour are care- 
fully mixed with 3y 2 grams of an 11 per cent, solution of potassium carbonate 
and 200 grams of water are added. This is mixed with the first solution, 
the stirring being kept up constantly. The complete mixture is then set 
aside in a vessel of hot water for half an hour to make it thinner and sweeter, 
after which it is again place'd over the fire and heated until the soup begins 
to thicken, then removed and stirred for five minutes, and again heated and 
removed. This process is to be repeated until the mixture is of a thin, fluid 
consistence and sweet. Finally the soup is boiled for a few minutes and 
poured through a fine sieve, after which it is ready for use. Liebig's original 
plan was to prepare each feeding separately; the recipe here given is for the 
entire day. 

2. kelleb/s malt soup. 

This is a modification of Liebig's soup and is more easily prepared : 
Fifty grams of wheat flour are stirred into 1/3 liter of milk and the mix- 
ture thoroughly sieved. In another vessel 100 grams of malt soup extract, 
or 100 grams of malt extract, added to 10 c.c. of an 11 per cent, solution of 
potassium carbonate in 2/3 of a liter of water is dissolved at a temperature of 
50° C. This malt extract solution is then added to the milk solution and the 



214 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

entire mixture is boiled. According to Keller Loflund's malt soup extract 
should be used in the preparation of the food. Keller's malt soup may be 
used for weeks and even for months as a diet for atrophic infants and some- 
times produces a sudden change for the better. In other cases the result is 
gradual, and at times this method of nutrition is without success. 

The chemical composition of the malt soup is as follows: fat 1.0-1.2 per 
cent, albumin 2.0-2.5 per cent., and sugar 70-80 per cent. The nutritive 
value of a liter, according to Rubner's combustion experiments amounts to 
808 calories. In cases in which the malt soup is without value I have em- 
ployed a mixture deficient in fat but rich in sugar, and in the preparation of 
malt soup other malt preparations have been used. Among these are the com- 
mercial powders in dry or crystalline form : 

a) Liebe's neutral malt extract, to be used in the preparation of malt 
soup in the same manner as Loflund's malt soup extract. 

b) Liebe's neutral food: One-sixteenth kgrm. (four heaping tablespoon- 
fuls) of malt extract mixed with 1/6 liter of milk and 1/3 liter of water, 
brought to the boiling point once and the solution poured through a sieve. 
The soup is then ready for use. 

c) Brunnengraber's crystallized malt extract: One hundred grams mixed 
in a liter of 1/3 milk (350 grams milk, 650 grams water) and stirred while 
boiling. 

d) Allenbury's infant food No. Ill (malted food) : Three tablespoon- 
fuls of malted food mixed with i/> liter of water and y 2 liter of milk, briskly 
stirred while boiling. After cooling the food is ready for use. 

If no beneficial results are obtained even after the employment of these 
substitutes for Liebig's original malt soup, a food first advised by Dutch 
physicians (Ballot, de Jager, Teixera de Mattos) as a general food, sometimes 
acts admirably in atrophy: 

3. BUTTERMILK. 

The preparation of this food is as follows : Fifteen grams of Kaiser flour 
are mixed with a few tablespoonfuls of cold buttermilk, added to the re- 
maining buttermilk (one liter) and, with the addition of 60 grams of sugar 
(and perhaps one teaspoonful of fresh butter), heated for fifteen to twenty 
minutes and constantly stirred, before the mixture is brought to the boiling 
point. The milk is allowed to boil up twice and is then emptied, hot, into 
previously sterilized bottles, sealed with a rubber stopper, and kept cool. 

There is great difficulty in obtaining good buttermilk. It must be pre- 
pared from sour cream and obtained fresh after the churning. It contains 
2.5-2.7 per cent, albumin, 0.5-1 per cent, fat and 3.0-3.5 per cent, sugar. Its 
acidity amounts to 7 c. c. { n NaOH. The nutritive value is very high : 714 
calories to the liter. 

Buttermilk is exceedingly well borne by many atrophic infants and in quite 
a number of instances leads to a permanent reparation of the nutritive dis- 
turbance. 

I must still emphasize that the trial of a nutritive mixture is not to be 



TREATMENT OF CHRONIC DIGESTIVE DISTURBANCES 215 

abandoned too soon, and this is of importance in regard to all the substi- 
tutes for milk. The organism must become accustomed to any form of 
nourishment and not before eight or fourteen da}'s can it be determined 
whether the food is proper or not. 

In the simple chronic digestive disturbances in which it is necessary to 
raise the nutritive condition as well as to ameliorate the chronic catarrhal 
phenomena and likewise the intercurrent intestinal disturbances of genuine 
atrophy we must invoke the entire arsenal of drug therapy which we employ 
in the acute digestive maladies. 

Among the astringents are tannigen, tannalbin, tannoform (0.5-1.0 every 
three hours or three times daily), honthin (0.25-0.5), tannopin (0.3-0.5), 
resorcin (0.1-2.0), perhaps in combination with calomel (0.002-0.003). These 
remedies must not be abandoned abruptly; in the course of a few days they 
usually cause constipation and if the remedy is stopped diarrhea is apt to 
recur. Therefore the drug should be continued for a time in gradually 
diminishing doses. 

If these drugs prove ineffectual, among the metallic agents lead acetate 
and silver nitrate are of special value : 

Plumb, acet, 0.005-0.05 

Op. pulv 0.001 

M. f. pulv. S. One powder -4 times daily. 
Or 

Solut. Arg. nitr 0.1 

Aq. dest 50.0 

Tinct. Opii gtt. iv-vi or codein. c . . 0.02 

M. S., One teaspoonful every 2 hours. 

Argil is also occasionally successful (Soltmann) : 

Argil depurat 1.0-2.0 

Aq. dest 50 

Syr. Cinnamomi 15.0 

Tinct, Opii gtt iv 

M. S., Bottle to be well shaken, one teaspoonful every 2 hours. 
Colombo or Ligu. campechiani may be employed: 

Decoct, rad. Colombo 10-15.0:100.0 

Or 

Decoct, lig. Campechiani. .10-15:100.0 
with or without the additions of tinct, opii gtt. 1-4. 



216 CHRONIC DIGESTIVE DISTURBANCES OF INFANCY 

Bismuth, subnitr. or tanicum 0.1-1.25 given in powder form every 2 hours 
is also serviceable. Neumann advises protargol 0.05.-0.1 :50.0 in teaspoonful 
doses. 

Bnteroclysis is of value in the chronic diseases of the colon. After a 
luke-warm enema of water the infant is placed in the knee-elbow position and 
a nozzle the length of a finger is placed on the rectal tube which is also 
supplied with a funnel. The irrigating fluids to be employed are common 
salt solution 0.6 per cent., starch enemata with opium, or various other solu- 
tions (salicylic acid 0.5-1:500 or tannin 0.5-1 per cent., albargin 0.4:250, 
plumb, acet. or alumin acet. 2.5:1000, arg. nitr. 1-2:3000). These are often 
of advantage, but they are also frequently without effect. The quantity for 
an injection is 50-100 c. c. 

In conclusion, in a review of the entire subject of the chronic digestive 
disturbances of infancy it must be obvious that we are dealing with one of 
the most difficult problems in the entire realm of pathology. In all of our 
efforts to conquer this angel of death of early infancy we must aim toward 
the utilization of two important factors, first the results and application of 
rich, practical experience in diseases of infants, and secondly a consideration 
of the individuality of the patient which will exclude a routine method of 
treatment. Even with the possession and with a comprehensive employment 
of these factors we have a problem confronting us the solution of which is 
often beyond our skill. 



INFANTILE SCURVY (BARLOW'S DISEASE) 

By H. NEUMANN, Berlin 

At the beginning of the twentieth century we encounter a peculiar disease : 
of recent recognition and understood by few, its innermost nature not suffi- 
ciently clear but probably a disease which will soon disappear, the attention 
which it has elicited is quite justified. The first clinical and anatomical pre- 
sentation of the pathologic picture we owe to Moller (1859, 1862), who 
spoke of the malady as acute rickets, and held that the similarity to scurvy 
was " purely external and symptomatic." Later the affection was designated 
" hemorrhagic periostitis," " multiple osteitis," " myelo-periostitis," etc. Its 
relation, however, to rickets has in the main been occasionally disputed and 
is to-day upheld by many authors. If we disregard the communications of 
Ingerslev (1871) and of Jalland (1873) the second period in the history of 
the disease began with a communication by Cheadle (1878), who demon- 
strated by its successful treatment the scorbutic nature of the affection. In 
1883 Thomas Barlow acceded to this view and amplified our knowledge of 
the disease by clinical histories and autopsy reports. It appears, therefore, 
to be another instance of historical injustice that this affection is named 
after the last-mentioned author. In Anglo-American literature the term 
applied to the malady is infantile scurvy ; in the French it is scorbut infantile. 
I should prefer the designation infantile scurvy. According to the latest 
investigations this properly characterizes the disease, especially as its relation 
to rachitis has been found to be quite accidental. It is true we must admit 
that this is a variety of scorbutus, brought about by external circumstances 
entirely different from those which prevail in the endemic affection, therefore 
we shall entirely disregard the designation " Barlow's disease." 

In the clinical description of infantile scurvy I shall adhere largely to 
the newer German experiences; these give slight, transient, and local devi- 
ations to the clinical picture for which we will find an explanation later. 
The disease begins commonly between the sixth and twelfth months, rarely 
in the fifth month, but occasionally between the thirteenth and fifteenth 
months; older children are not exempt. [Nor are babies very much }^ounger. 
— Editor.] In the summary of 54 observations of HeubnerV and in 40 cases 
of my own scurvy began once in the fifth month, 9 times in the sixth month, 
10 times in the seventh month, 20 times in the eighth month, 16 times in the 

1 Heubner, " Ueber die Barlow'sche Krankheit." Berl. klin. Wochenschr., 1903, Nr. 3. 

217 



218 INFANTILE SCURVY (BARLOW'S DISEASE) 

ninth month, 13 times in the tenth month, 10 times in the eleventh month, 
7 times in the twelfth month, twice in the thirteenth month, 4 times in the 
fourteenth month, and once each in the fifteenth and twenty-first months. 1 
In regard to sex, in Heubner's and my cases males were somewhat more fre- 
quently affected (of 105 children 62 were boys), while in the large American 
collection males and females appeared to be attacked almost equally. This 
may be explained by the fact that in the German cases more children de- 
veloped the disease during the first year — the typical period — when the male 
sex, as is well known, shows a greater morbidity. The malady usually attacks 
children w r ho are comparatively healthy and well-nourished and who are not 
at all or only slightly affected with rickets. Heubner noted severe rachitis 
only twice in 19 cases, and in 34 scorbutic patients of my own there were 6 
mild and 2 marked forms of the affection. 

According to early reports infantile scurvy is a disease of the winter and 
spring months, and is much less intense during the warm season. As a mat- 
ter of fact there is a conspicuous, although inconstant variation in different 
months — in 65 cases of Heubner's 36 occurred between March and June, 
15 from October to December; in 32 of my cases 14 occurred between March 
and May and 12 from July to September, the latter therefore during the 
warm season. 

SYMPTOMS 

Prior to the appearance of the disease the child often becomes pale; the 
ingestion of food may be interrupted to such an extent that the body weight 
may lessen instead of increase. Usually the attack begins suddenly with 
tenderness of one leg and early involvement of the other. At first the limbs 
may be crossed, the normal leg supporting the affected member; later both 
legs are lightly flexed at the hip and knee and turned outward, or less fre- 
quently are drawn up against the trunk. Although this attitude suggests 
paralysis such a suspicion may be dismissed at once; the muscles are relaxed 
merely to diminish the pain. Painfulness is evident when the child is dried or 
bathed, when it is raised or is carried with hanging legs, or when the limbs 
are touched. Even if the bath has a soothing effect the legs are not moved, 
and the child cannot be seated because of pain. At first the patient is quiet 
so long as the limbs are undisturbed; later, however, anticipated movements 
will provoke crying: raising of the bed-clothes, or the approach of anyone, 
particularly a stranger, to the bed causes a scream of fear. Finally, the pain 
is sufficient without touch to occasion whimpering or crying even in sleep, 
in so far as this is retained. In the course of a few days a deep, tense swell- 
ing appears upon the thigh, usually at the lower end or passing from there 
to the shaft, and gives to it a spindle shape. As a rule the swelling is not 

x The great group of American statistics, to which we shall frequently allude, can- 
not be utilized here. Reports of this collection will be found in The British Med. Jour., 
1898, II, and Jahrb. f. KinderheilJc., Bd. LI. 



SYMPTOMS 219 

sharply defined and is immovable. The overlying skin may be adherent and 
present a tense and glistening appearance. Redness and heat are absent. The 
circumference of the thigh may be increased decidedly. 

In rare instances there are evidences of infraction. In contrast to disease 
of the thigh, which is always present in typical cases, painful swellings of the 
lower leg, especially at the upper end of the tibia are rare, and usually appear 
simultaneously with the hip affection. In the arms tenderness and pseudo- 
paralysis are uncommon ; swelling also is often absent notwithstanding intense 
pain. The local and functional disturbances are slight. Less frequently there 
is implication of the ribs, the vertebrae, and the bones of the skull. Under 
two circumstances a very peculiar picture arises: When all of the true ribs 
near the boundary of the cartilaginous bone are bent the sternum sinks as 
if it were pressed inward; when the walls of the orbit are involved the eye- 
ball is protruded. This protrusion soon affects both eyes, without marked 
limitation in movement, and may at intervals increase. 

In contrast to 47 cases of disease of the thigh, Heubner saw the lower 
leg attacked 21 times, the bones of the orbital cavity 4 times, but rarely the 
forearm and ribs. I found the thigh attacked 35 times, the lower leg 7 times, 
the plate of the orbital cavity 4 times, the arms 10 times — in most instances 
reported by the parents — and the ribs once. 

The swelling, even when the skin is involved, does not produce a true 
edema; on the contrary, when there is swelling of the lower leg the edema 
appears at the end of the tibia or on the foot. The swelling over the bones 
indicates hemorrhage under the periosteum; the hemorrhage may, however, 
also involve the subcutaneous tissue. This is noted most frequently in the 
eye, where, prior to or simultaneously with the projection of the eye-ball, a 
swelling of the upper or, more rarely, of the lower eye-lid usually appears 
which is caused by hemorrhage, as is shown by the later discoloration. Hemor- 
rhage — punctiforrn or larger — into the skin alone, without simultaneous deep 
hemorrhage, is rare (7 times in 40 of my cases, 7 times among Heubner's) 
and hemorrhage into the mucous membranes is also uncommon; I once saw 
hemorrhage under the conjunctiva. On the other hand, the mucous mem- 
brane around the teeth, or at their points of insertion is usually affected soon 
after the onset of the disease so that a normal mucous membrane in this 
region is unusual (in 50 of Heubner 's cases the mucous membrane around 
the teeth was found normal 6 times, and among 23 cases I found a normal 
condition 5 times). At first there is slight redness; later this changes to a 
bluish tint and the mucosa becomes constantly more tumescent until it covers 
the tooth like a blue vesicle. This vesicle may rupture at its summit and 
give rise to more or less severe hemorrhage, while at the point of rupture an 
ulcer is formed which, according to Barlow, may undergo decomposition. 
This disease of the mucous membrane of the teeth is usually more marked 
upon the upper jaw. 

Clinically, the internal organs are less involved. Disease of the kidney 
is of greatest importance. In very rare cases — in a severe general affection — 



220 INFANTILE SCURVY (BARLOW'S DISEASE) 

there is an irritation of the kidney with a moderate amount of albumin and 
a few easts. Hemorrhage from the kidney is more frequent; the urine may 
be tinged with red, but commonly it shows a fresh red discoloration. It con- 
tains numerous red blood-corpuscles, occasionally cylindrical, scant hyaline 
or granular casts, which may be covered with red blood-corpuscles and renal 
epithelium, moderate amounts of albumin (the highest quantity I found was 
1.4 per 1,000), and a sediment of uric acid salts. Heubner found "hemor- 
rhagic nephritis" 6 times in 65 cases. In my cases, according to my own 
observation or the analysis of the urine, blood was absent 12 times (in another 
series of cases nothing can be stated in regard to this, and once the nephritic 
urine was free of blood), while in 7 cases I was able to demonstrate hemor- 
rhage. 1 

Hemorrhage of the intestinal mucous membrane is rare and shows itself 
by a trace of recent blood or hemorrhagic mucus in the feces with occasional 
irritation of the colon. Hematemesis is uncommon. 

Enlargement of the spleen is so extraordinarily infrequent that its con- 
nection with Barlow's disease is not positive. 

Convulsions due to the pressure of subdural hemorrhages (Cassel) have 
occasionally been reported. 

Simultaneously with the development of the disease in the bones and in 
the teeth there is impairment of the general condition, usually preceded by 
constipation or hard feces. Ingestion of food becomes difficult, if it has not 
already suffered prior to the outbreak of the disease. At first the child is 
eager for food but after a few attempts to suck, the nipple is forced away by 
the tongue, the child turns its head aside and closes its mouth firmly, or beats 
the bottle with its hands. Even the sight of the bottle induces crying and 
not until the child is sleepy is it at all possible to give nourishment with a 
spoon. Naturally this impairs nutrition. 

Sweating of the entire body, or at least of the head, is an almost invariable 
occurrence. Increasing debility, and in particular a general pallor of the 
skin, which may become extreme, are noted, as well as very irregular fever, 
the exacerbations of which are in association with renewed hemorrhage. 
Among 24 cases, the temperature of which was taken by myself, fever was 
present in 15. Cassel noted a febrile temperature 7 times in 11 carefully 
investigated cases. 

However, it must be expressly emphasized that the development of the 
clinical picture follows no definite law. There are cases in which the pallor, 
notwithstanding well-defined symptoms, is so slight that its recognition must 
depend upon the mother, who can make a comparison with the former con- 
dition. Inversely, I noted a decided sallowness of the face and severe cachexia 
in a child whose ribs and legs were very sensitive but who showed no distinct 
swelling nor the slightest change in the gums (fracture of the thigh occurred 
during examination by a physician). 

1 See conclusion of article. 



PATHOLOGY 221 

As a rule, in the typical cases the first examination of the child reveals 
pain and swelling in the legs, and, in so far as teeth exist, disease of the gum. 
The development of other symptoms is variable; sometimes the bones are 
most affected, at other times the constitutional condition; in rare cases there 
is a decided tendency to cutaneous hemorrhage. If the deleterious factors 
which are the cause of the disease continue uninterruptedly a fatal outcome 
may be expected. Exceptionally the lethal termination has occurred in three 
or four weeks after the appearance of the typical symptoms (Xaegeli) ; death 
seldom occurs before the seventh or eighth week and usually the disease lasts 
three to four months. The individual case may show an irregular severity. 
These fluctuations, and with them the protracted course, are probably due to 
a temporary diminution or abandonment of the deleterious agent. For the 
same reason there is no definite law in regard to mortality. Eecovery — in 
the absence of complications — or death is dependent upon the decrease or con- 
tinuance of improper nourishment. That 15 to 20 of every 100 of these cases 
have perished must be ascribed to an insufficient knowledge of the cause of 
the malady. 

The foregoing facts relative to a purposeful or accidental removal of the 
cause also indicate that the symptom-complex attains a varied development. 
In the prodromal stage — with pallor or rejection of food — the outbreak of 
infantile scurvy may be prevented, or after the first indication of a symptom 
the process can be aborted, by a change of nourishment. For example, in a 
flourishing infant I was able to arrest the disease before s} T mptoms other than 
sensitiveness of the legs (without swelling) had appeared. Hematuria may 
exist for some time as an unassociated symptom, without sensitiveness or swell- 
ing of the gums. Among 45 cases I saw 5 abortive types of this kind. 
On the other hand I have only twice found hemorrhagic urine in well-defined 
clinical pictures of the disease. 

If the malady is brought to a favorable termination by a proper change in 
the nourishment, the pains vanish with surprising rapidity — in my experience 
as early as one or two days — the inclination for food increases constantly, and 
the quiet child now takes nourishment well and appears greatly improved. 
The gingival swelling recedes without local treatment and in eight or ten days 
the gums may be normal. The cutaneous hemorrhages run their color scale 
and disappear. The swelling of the bone subsides somewhat more slowly and 
may require some weeks for its complete extinction. The hematuria usually 
ceases in a few days but after a protracted course it may continue for weeks. 
As a rule, not many weeks after the institution of treatment the child may be 
regarded as cured. 

PATHOLOGY 

The gross anatomical foundation of the clinical picture has long been 
known. Its refinement has to some extent been accomplished in the last few 
years by extensive investigations (Naegeli, Schoedel and Nauwerck, Schmorl, 
v. Recklinghausen, Jacobsthal, Ziegler). The swelling on the bone is due 



222 INFANTILE SCURVY (BARLOW'S DISEASE) 

to copious effusions of blood which commonly cause a decided upheaval of the 
periosteum and undergo involution in the usual manner. If new hemor- 
rhages occur with the old, the organized blood-clot produces a stratified 
structure. 

The osseous hemorrhages which occur in the bone-marrow as well as under 
the periosteum, together with hemorrhage into the muscles, into the subcu- 
taneous tissue, and into the internal organs, are the manifestation of a hemor- 
rhagic diathesis. No sufficient explanation for this is found in the blood. Its 
morphologic examination in life has shown only slight change in the red blood- 
corpuscles corresponding to a moderate anemia, and the leukocytes are cer- 
tainly not increased, although perhaps there is a relative preponderance of 
lymphocytes. On the other hand, peculiar to infantile scurvy are the changes 
in the hones, which are distinct from the possible rachitic changes. In the 
diaphysis of the bone in particular the normal bone-marrow has been trans- 
formed into a gelatinous and fibrous material, the osteoblasts are scant, the 
normal ossification arrested. According to Ziegler there is also resorption of 
bone. The bony trabecular are therefore thin and scant. For this reason 
fractures readily occur in the new and thinnest trabecular — hence below and 
not within the cartilagino-osseous border. In advanced atrophy of the bone, 
however, fracture is more frequent toward the middle of the diaphysis, and 
the decided displacement of tissue which then results gives rise to hemorrhages, 
or augments those already present. 

Fractures and hemorrhages are produced by the slightest mechanical influ- 
ences. The first and most marked appearance of the affection in the legs is 
readily explained by their greater use at the time of life in which the disease 
occurs (Michael Cohn) : It is due to the stamping and striking of the legs, 
attempts to sit, stand, and walk, as well as to slight torsion and shock (drying 
the child, bathing, stumbles, falls, etc.). Cutaneous hemorrhages are pro- 
duced by slight pressure or blows. Hemorrhage into the eye-lids and orbital 
cavity have sometimes been the result of prolonged crying. The affection of 
the gums is due to the pressure exerted upon the mucous membrane by the 
teeth in dentition and perhaps also to external causes, as biting. The use of 
the already erupted teeth produces an irritation which, as upon other occasions 
is usually greater upon the upper jaw. It is a notable fact that in the attack 
on the osseous system the joints are not implicated. Inflammatory symptoms 
do not appear. 

Anatomical investigation provides no explanation as to the cause of the 
disease. The hemorrhages are not characteristic, although their preference 
for the bones and gums resembles scurvy. The peculiar affection of the bony 
tissue cannot be utilized in this connection because corresponding investiga- 
tions in epidemic and endemic scurvy do not exist. Nor does the clinical pic- 
ture give enlightenment, particularly as endemic scurvy has not been observed 
in nurslings. Although pathologists do not yet coincide as to a connection 
of infantile scurvy with rickets the clinician may at once reject such an 
assumption. Scurvy is seldom observed in rachitis, and rachitis as a rule, 



ETIOLOGY 223 

does not accompany infantile scurvy. On the other hand, sufficient explana- 
tion is given by etiologic research; the correctness of the result is proven by 
the success of treatment, which is founded upon it. 



ETIOLOGY 

Infantile scurvy is observed only in children who have been artificially fed 
for several months. Neither Barlow nor any other competent recent investi- 
gator has reported a contrary experience, and although under quite exceptional 
circumstances the disease is noted occasionally in a breast-fed child, the ma- 
jority of the few such reported cases are certainly mistaken. 1 Although the 
harmful agent undoubtedly lies in the quality of the artificial food, neverthe- 
less we must be cautious in our decision. The monotony of the food is occa- 
sionally mentioned as the cause, but this view may be rejected, since there is 
no greater variation when natural food is administered at the same period of 
life. Simple under-nutrition also does not produce infantile scurvy. 

The food which is at fault consists mostly of milk in certain preparations, 
infant foods, or a combination of both. In some cases other food has been 
added, the influence of which will be explained later. Many communications 
mention only the food product, in the belief that the deleterious element is 
thereby designated, and say nothing of its mixture with milk or the manner in 
which the milk is prepared. In other instances the administration of milk 
is mentioned, but through ignorance, or because of certain theories, the nature 
of its preparation is not reported. Finally, the author has not always known 
that any prolonged method of feeding was without importance, but that the 
food which was chosen for a number of months prior to the disease is of mo- 
ment, whether administered uninterruptedly, or alternately with another 
which was just as objectionable. For all of these reasons many reports in the 
literature are valueless in the etiology, and many of the objections to the theory 
which is to be developed are untenable. Therefore, in this discussion I must 
depend largely upon my personal experience. 

First, we may assume that exclusive feeding with prepared infant foods 
which do not contain milk — apart from some unimportant mixture, as tea or 
broth — may develop infantile scurvy. I am not aware of any positive case of 
this kind in German literature which has been fully detailed; but in England 
and America several such observations have been reported (for example, Case 

1 In some of the eases which have been much quoted a period of artificial nutrition 
covering several months intervened between the period of natural feeding and the out- 
break of the disease. I saw a breast-fed child, aged 5 months, who, after the first 
month, was occasionally fed condensed milk. This child developed tenderness of the 
legs and hemorrhagic nephritis. In the following week there was a varied amount of 
blood in the urine, with scant granular and hyaline casts, and a quantity of albumin 
equal to 4 per 1,000, later 2 per 1,000. Although this was a case of nephritis, there was 
an undeniable resemblance to infantile scurvy. This sprightly child, who continued 
to be nourished at the breast, had traces of albumin in its urine for over two months. 



224 INFANTILE SCURVY (BARLOW'S DISEASE) 

1 of Cheadle, 1 Lancet, 1878, Nov. lfi. In those countries, th< refore, the affec- 
tion is not rare, after the prolonged use of infant foods — whether or not they 
contain milk in addition to carbohydrates. Milk products in condensed or 
liquid form which are partially prepared by energetic chemical manipulation, 
partially by high heat, are a further cause. Finally, infantile scurvy is 
observed after administration of uncombined milk, which, with or without the 
addition of mucilage, flour, or sugar, has been heated for a certain time in 
manufacture or at home. In Germany examples of this kind are numerous. 
In this condition a great role is played by " sterilized " milk — a designation 
which fails to define the duration and degree of heating: On the one hand 
we must consider milk which is decomposed in its manufacture, as is shown 
by the brown discoloration, on the other hand milk which has only been boiled 
in the Soxhlet apparatus for a certain time. Just as little is conveyed by the 
expression " Pasteurized milk." Milk of this kind has been heated at various 
high temperatures for an indefinite period without being brought to the boil- 
ing point. In the year 1901, Pasteurized milk, which is mentioned in the 
following observations, was heated to a high temperature (95° C.-203 F.) ; 
since 1902 it has been heated for half an hour at a temperature of 60° to 65° 
C. (140° to 149° F.). The following reliable investigations are examples of 
the degree of heat to which the milk is sometimes subjected. In Cassel's 
experience the milk was in two instances sterilized excessively, twice Pasteur- 
ized milk was heated in the house from 20 to 30 minutes, and nine times fresh 
milk was heated in the house from 20 to 60 minutes. I have observed the fol- 
lowing methods of heating: Twice, sterilization in manufacturing and at 
least once boiling at home for three-quarters of an hour; Pasteurized milk 
heated additionally in the Soxhlet apparatus, once for 45 minutes, three times 
for 20 to 25 minutes, in a milk cooker, twice for 20 minutes, in the Soxhlet 
apparatus, three times for 15 minutes, once for 10 to 15 minutes, twelve times 
for 10 minutes, in milk cooker, once for 10 minutes; in one case, 15 minutes 
in the Soxhlet apparatus for 3 months, and during the following 3 months 7 
minutes ; in one case 10 minutes for 3 months and 2 to 3 minutes the following 
5 months; in two cases 4 minutes and 1 minute, respectively (by the watch). 
Condensed milk was given in one case for 3 months, and in the following 5 
months Pasteurized milk was boiled in a casserole for a few moments. In 
another case plain milk for 8 months, then Pasteurized milk boiled in the 
Soxhlet apparatus 12 minutes for 2 months. In another case fresh milk 
boiled 15 minutes for 2 months and 10 minutes for 3 months, then for 6 
months Pasteurized milk boiled in a Soxhlet apparatus 10 minutes. In three 
cases fresh milk was boiled in the Soxhlet apparatus 15 minutes, in two cases 
10 minutes. The following case is noteworthy: For 3 months Pasteurized 
milk was boiled in the Soxhlet apparatus 5 to 6 minutes, then, for 6 months, 
fresh milk was boiled for half an hour at a temperature of 70° C. (158° F.) 

1 Here, in addition to oatmeal, " rusks," i.e., zwieback, which may have been pre- 
pared with milk. 



ETIOLOGY 225 

and kept at that temperature with the thermometer. It is to be remarked 
that in neither of the above cases in which Pasteurized milk was cooked in the 
Soxhlet apparatus for 4 minutes and 1 minute, respectively, could a boiling 
temperature have been reached 1 so that not boiled milk but milk heated under 
100° C. (212° F.) may have a deleterious effect, as is shown by the American 
statistics. 

Improper nourishment must be prolonged for months before infantile 
scurvy arises. According to my observations, children who have had improper 
food from their birth have shown unmistakable symptoms most frequently 
between the seventh and eighth months (17 times), more rarely between the 
fifth and sixth months (11 times) and exceptionally between the ninth and 
eleventh months (8 times). If infantile scurvy develops later the damage was 
not begun at birth but a greater or less time afterward and continued for at 
least five months. For example, I saw a child affected at 13 months, which 
was fed at the breast for the first 5 months; another child was attacked at 
20 months who, instead of having raw milk was for a few months given 
Pasteurized milk from the same dairy, which was boiled in the Soxhlet appa- 
ratus. Literature furnishes numerous examples of this peculiar regularity 
in the outbreak of the disease. One of the oldest children affected with infan- 
tile scurvy was a child aged 2 years and 9 months, who had been nursed until 
2 years of age, and had then been fed bread, butter, tea, sausage occasionally, 
and to some extent brandy and water (Cheadle). 2 In general this affection 
is not found much beyond the second year because after that age a mixed 
nourishment is given. 

The kind of food which produces infantile scurvy has been mentioned, 
and, to prevent misunderstanding, I must reiterate that only when this form 
of nourishment has been continued for an average eight months does the dis- 
ease develop. The greater the decomposition of the food from chemical effects 
or from heat, the more rapid and severe in general is the onset. This is espe- 
cially evident in the use of artificial or intensely heated milk preparations, such 
as albumose and fat milk, which give rise to such severe grades of anemia as 
rarely exist when the milk is prepared at home. 

On the other hand it seems peculiar that Barlow's disease has arisen — 
exceptionally, it is true — from the use of prepared milk under which many 
other children have remained perfectly well. The antecedent history of these 
cases occasionally reveals a previous mild or severe intestinal disturbance 
(dyspepsia, intestinal catarrh). 3 In other cases only severe constipation could 
be discovered, which is very usual after the ingestion of milk that has been 



1 According to the investigations of my assistant, Dr. Forest, when milk in the 
Soxhlet apparatus is at the same temperature as the water, it attains the temperature 
of boiling water five minutes after the water has begun to boil; if the bottles are in 
water only 1 cm. deep nine minutes are required. 

2 Lancet, 1878, Nov. 16. 

3 In the history of 39 cases I found dyspepsia and intestinal catarrh 12 times, and 
in 5 instances other important affections. 

16 



226 INFANTILE SCURVY (BARLOW'S DISEASE) 

cooked for some time. Apart from these factors, however, there is apparently 
an obscure individual predisposition which must be invoked, particularly in 
those cases in which the nutritive damage is slight. Finkelstein reports the 
case of a child who, as its brother had previously been attacked with infantile 
scurvy, was fed with boiled milk and vegetables, but nevertheless contracted 
the malady. 

In the main, however, we must look for the cause of Barlow's disease in 
exclusive and long-continued nutrition with certain foods which have under- 
gone a decided change, particularly from overheating. This also satisfactorily 
explains the temporary and local dissemination of the disease. The avoidance 
of natural nourishment in the last decades is not responsible for its increase, 
for infantile scurvy was also unknown in districts in which breast-feeding was 
not unusual, and where even now the attacks in artificially fed children are 
infrequent. On the contrary, the appearance of infantile scurvy has to do with 
the theoretic and practical evolution which the problem of artificial infant 
feeding has of late undergone. In the last decades, with a better knowledge of 
the chemical composition of milk, the production of nutritive preparations 
as substitutes for milk has enormously increased. Furthermore, the danger- 
ous intestinal catarrhs, which had been recognized as due to the decomposition 
of milk, since about 1880 have been known to originate from bacterial con- 
tamination. An attempt was made to overcome this contamination by pro- 
longed boiling. Although this procedure has been somewhat restricted in the 
last few years, there has been a development in another direction, in that the 
milk is now subjected to Pasteurization at the dairy. This alone, or after 
additional heating at home, may have a deleterious effect. 

These facts are in conformity with the more frequent occurrence of infan- 
tile scurvy, especially in England and in the United States, where infant feed- 
ing in the direction above indicated has been particularly developed. From 
1889 to 1894, 106 cases were reported, and the collective investigation under- 
taken in 1898 gave 379 cases which were referred essentially to this form of 
nourishment. The disease is also common in Holland, especially in Friesland 
— de Bruin collected 61 cases in 1893 — but information as to the nutrition of 
the diseased children is wanting. There are few cases in France and in 
Switzerland, notwithstanding the frequent employment of sterilized milk in 
those countries, but it remains questionable whether milk of this kind is often 
fed exclusively for five months, and upon the other hand, whether the knowl- 
edge of infantile scurvy is sufficient to establish a diagnosis. In Germany, 
Rehn, who was the first to devote special attention to the disease in that 
country, saw only 7 cases from the year 1878 to 1889. Following Rehn, 
Heubner interested himself particularly in the affection but from 1876 to 1889 
saw only 2 cases ; from that period up to 1900, 28 cases. As the result of special 
inquiry in Schleswig-Holstein v. Starck reported a number of cases of infantile 
scurvy which were due to prolonged boiling of the milk in the Soxhlet appara- 
tus ; more important, however, was his discovery in Hamburg of a small epi- 
demic which was proved to have arisen from the feeding of milk sterilized in 



ETIOLOGY 227 

the laboratory. In Berlin, up to the year 1900 inclusive, infantile scurvy was 
comparatively rare, although the manufacture of albumose milk brought forth 
on occasional augmentation. Meanwhile, from the year 1896 to 1900 Heub- 
ner, Cassel and myself together saw only 32 cases, while from that period the 
number increased suddenly to such an extent that in the years 1901-2 the same 
observers personally treated 83 cases. According to my own experience this 
increase is to be referred to the ingestion of milk which was Pasteurized in the 
dairy and afterwards heated at home, and its suddenness is explained by the 
fact that the milk of the dairy in question was not Pasteurized until 1901. 1 

The prolonged use of infant foods and prepared infant milk is expensive; 
the possession of a Soxhlet apparatus requires an outlay too great for the poor. 
This is the reason, set forth by all authors, that infantile scurvy occurs only 
among the better population. In Berlin the children of the well-to-do middle 
class in particular are affected. Here, owing to professional or popular advice, 
we see the over-careful mother — possibly with a watch in her hand — accurately 
follow the prescribed time for boiling, or even prolonging it from a theory of 
her own. In support of older professional views she is careful not to allow her 
child other food than the milk until a definite period. Exceptionally, the dis- 
ease is found also among the poorer class, who attempt beyond their circum- 
stances to provide the best for their children. As a rule these children are all 
well-nourished and free from hereditary rickets. On the other hand, a small 
number of poor children who are sickly and rachitic are affected under special 
circumstances with infantile scurvy: in a hospital for a long time, and fed 
according to the newest artificial methods, the reverse effect of these measures 
shows itself in the form of infantile scurvy ; or they are nourished continuously 
and exclusively with food preparations or over-heated milk for some accidental 
reason, especially to prevent a renewed intestinal catarrh. These children sup- 
ply the material for the latest anatomical investigations ; more or less rachitic, 
they have been the cause of the unending dispute as to the connection of infan- 
tile scurvy and rickets. 

It was surprising that the affection here described was at first declared to be 
scurvy. Scurvy ordinarily appears in endemics, among the crews of ships, or 
among a starving population; young children are not mentioned among the 
patients ; 2 probably those in the first year of life — provided they are not breast- 
fed — succumb from the unhygienic and economic conditions which predispose 
to scurvy before the disease can develop. That small children may develop 
typical scurvy is shown by the cases from the older literature of the disease 
under consideration. 3 More essential is the fact that in the endemic scurvy of 
adults, as well as in the typical cases of childhood, the symptoms do not deviate 

1 Among 26 cases treated during this period by me 23 had been fed with this milk 
for some months. The previously mentioned cases in the year 1903 also included 
numerous examples. 

2 See Inaugural Dissertation of Tschudakoff (Berlin, 1901), who reported 1,153 cases 
of scurvy in Russia in the years 1898-99. 

3 Cases 1 and 3 (the latter quoted above) by Cheadle, Lancet, Nov. 16, 1878. 



228 INFANTILE SCURVY (BARLOW'S DISEASE) 

fundamentally from the affection which has been described: in every case there 
is anemia, swelling and painfnlness of the legs, with more or less flexion and 
outward rotation, 1 swelling and ulceration and even putrefaction of the gums. 
Apart from the influence of certain physiologic conditions, as were shown 
above, upon the localization in nurslings, infantile scurvy appears peculiar only 
in so far as it sliows the symptoms of scurvy alone — without simultaneous ema- 
ciation or other disease due to improper nursing and nutrition — and moreover 
is not developed to the extreme extent. On the contrary, the children are care- 
fully looked after, plentifully nourished and as a rule well developed. Hence 
infantile scorbutus, as a pure form of scurvy, is especially suitable for study 
of the nutritive conditions, and therewith must be considered that form of 
nourishment by which curative results are positively obtained. 

As in endemic scurvy, so also in the infantile form, the predisposition is 
individual. It cannot be denied that with a marked predisposition even a 
slight deterioration of food (sometimes from the breast) may produce cachexia 
with a tendency to hemorrhage; but it will probably at no time be a case of 
simple inanition. In infantile scurvy the good nutrition, which is the rule, 
shows that there is neither a decreased ingestion of food nor a special limitation 
of absorption and assimilation. If super-heated milk is to be regarded as a 
cause of scurvy, a careful weighing of all investigations shows its digestibility 
to be little or not at all limited. Even though organic combinations of phos- 
phorus, the presence of which is necessary for the accumulation of tissue 2 
appear to be decomposed by heating, this loss is not of importance, particularly 
as prolonged additional feeding of an uncoagulated egg — nothwithstanding a 
plentiful presence of lecithin — is not capable of preventing the development 
of infantile scurvy. We may therefore disregard a possible damage of nutri- 
tion and investigate as a causative factor the general constitutional disturbance 
which is present in infantile scurvy. 

The fundamental and also practically important question is whether scurvy 
is due to the absence of products which, although not necessary for a gain in 
weight, nevertheless are essential for development, or whether it arises from 
the presence of substances which are injurious. To confine our remarks to 
milk, modern physico-chemical methods of investigation, in spite of their 
minuteness, show r neither a decrease of the molecules (perhaps through separa- 
tion upon heating) nor an increase of the same which might follow the split- 
ting of salts from their union with organic combinations. 3 Therefore there can 
be only minute changes in the milk through heating. If we consider the dis- 
appearance of products by cooking all action of ferments will unquestionably 
be arrested at the boiling temperature — so rapidly, indeed, that even in milk 

1 Compare a characteristic picture of a woman in " Starving Russia," by C. Leh- 
mann and Parvus. Stuttgart, 1900, p. 309. 

2 Cronheim and Erich Miiller, Zeitschr. f. didtet. und phys. Therapie., 1902-3, Bd. VI, 
Heft 1-2. 

3 Compare H. Neumann, " Remarks upon Barlow's Disease." Deutsche tried. Wochen- 
schr., 1902, Nr. 35 and 36. 



ETIOLOGY 229 

which is boiled by the ordinary method they will never be present: Their 
absence, therefore, cannot be of importance. Less calcium will be absorbed in 
the intestine from boiled milk than from raw milk ; and apparently the metab- 
olism of the calcium x also surfers : But that this has to do with infantile 
scurvy, and not perhaps with rickets, must first be proven. We might more 
readily observe that the introduction of iron from cow's milk, as to amount or 
in a tissue-producing form, is damaged by heating: According to Bunge the 
danger of a decrease in iron and of anemia exists even with natural food, so 
that if newborn animals are fed too long upon milk exclusively such a fear is 
certainly justified when the very slight quantity of iron in the cow's milk is 
still further decreased by heating. It is true, boiling does not precipitate note- 
worthy amounts of iron from cow's milk and it must also be remarked that 
with the use of boiled milk exclusively neither the addition of organic nor of 
inorganic iron combinations can prevent or cure scurvy. Furthermore, infan- 
tile scurvy may develop with a continued and exclusive ingestion of meat, not- 
withstanding the fact that there is then no deficiency in iron. 2 Finally, 
better's view must be mentioned, 3 that the citric acid present in the milk is 
precipitated by boiling and forms a combination difficult to dissolve. Granted 
that cow's milk contains about twice as much citric acid as human milk, boil- 
ing may all the more readily lead to a perceptible deficit, as the quantity of 
citric acid varies according to the individual, season, etc. While Netter re- 
gards citric acid as the antiscorbutic portion of the milk, he refers to the spe- 
cific action of the vegetable acids contained in vegetables. This hypothesis, 
however, appears erroneous, for the reason that, in the Arctic region for ex- 
ample, man may remain perfectly well with an exclusive diet of fresh meat, 
without milk or vegetables. On the contrary, we are inclined to the view that 
in the case of scurvy toxic products are mediately or immediately taken up in 
the economy which — perhaps through internal secretion — are not rendered in- 
active in the juices of the body, or at least to a sufficient extent. The anti- 
toxic faculty of the tissues and their juices may vary individual^, and besides 
may be decreased by preceding disease, especially of the intestine. With a 
prolonged ingestion of toxic products such as are contained in spoiled pre- 
served meats or in meat that is not fresh, there may be a development of scurvy 
— as we know from its occurrence at sea. Johannessen's view that toxins 
which originate from dead bacteria in the milk may act in the same manner, 
cannot be admitted in the case of infantile scurvy, for as a rule this affection 
arises after the ingestion of milk which is free of bacteria. On the con- 
trary, when we consider the development of infantile scurvy after the use of 
flour and milk preparations and of too greatly heated milk, we must remember 
that the albumins in the flour and in the milk have been exposed to chemical 
action or to the effect of heat, and have thus undergone more or less decompo- 
sition or at least a change in their intramolecular combination. It has been 

1 Cronheim and Erich Miiller, I. c. 

2 William P. Xorthrup, I. c, Case 8. 

5 Bull. d. 1. Sloe, de Pediatric de Paris, Octobre, 1902. 



230 INFANTILE SCURVY (BARLOW'S DISEASE) 

proven that in too greatly heated milk, apart from the destruction of other 
constituents, split products of albumin (leucin, tyrosin, sulphuretted hydrogen) 
are present, and also that under artificial digestion deleterious products, such 
as resorbable ammonia, may be formed in large amounts (G. Klemperer). 
Therefore scurvy may, with some likelihood, be regarded as a more or less 
chronic intoxication/ whether the poisons develop in an exogenous manner in 
the food, from bacterial decomposition, through chemical action, or from the 
effect of heat, or whether they originate endogenously in digestion. Besides, 
according to the nature of the food and the degree of nutritive damage, various 
deleterious products may become prominent and influence the clinical picture; 
at least it is conspicuous that the marked change in albumose-milk, and in 
greatly super-heated fat-milk because of transportation, may produce severe 
anemia and cachexia (in one of my cases hemorrhage occurred without a mani- 
fest cause), while in many other instances nourishment with milk heated in 
the Soxhlet apparatus produces the characteristic hemorrhages but not marked 
anemia and cachexia. We have already found that there is apparently no im- 
mediate anatomical connection between the changes of the bones and their 
marrow and the hemorrhagic diathesis. 



DIAGNOSIS 

Having gained an insight of the picture and nature of infantile scurvy we 
are better able to consider the diagnosis. As the knowledge of this disease is 
not extensive, a correct diagnosis is rarely made. The confusion which arises 
is of a surprisingly manifold nature. Very frequently a single symptom only 
is observed; often also many symptoms are combined and thereupon an incor- 
rect diagnosis is made. The disease of the gums is usually referred to difficult 
teething, and is therefore considered of no great importance. We are accus- 
tomed to look upon this as an unavoidable annoyance, and hence, in a moderate 
affection, it is thought that there is no connection with the pain in the legs. 
If, in considering the hemorrhages, the swelling is regarded as the essential 
and the sensitiveness is overlooked, tumor formation is thought of; in the 
thigh osteosarcoma, in the eye a retrobulbar tumor ; more than once the swell- 
ing, the nature of which was not clear, has been attacked surgically. If the 
painfulness in the bones is heeded, particularly when fever is present, it is 
natural to think of inflammation — periostitis or osteomyelitis ; in favor of the 
latter also is the multiple localization and the course, which is sometimes pro- 
tracted, sometimes rapid. The presence of albumin in the urine would thus be 
explained. It is true that at the onset of the swelling there is rarely fever, 

1 The very rare cases of infantile scurvy which occur in breast-fed children — in so 
far as they are not at all positive — must be tested from this point of view. I know 
of only one case, that of Love (Journ. Amer. Med. Assn., October 12, 1895). Here the 
mother, who also was debilitated, and the child, aged 9 months, were subjected to 
strong mercurialization, so that the case may have been one of severe mercurial in- 
toxication. 



DIAGNOSIS 231 

which is so apt to he present in an inflammatory process, and, on the other 
hand, if the swelling is of long standing its stationary condition is opposed to 
inflammation. A certain similarity with the painful swelling of the bone in in- 
fantile scurvy is found in syphilitic osteochondritis when associated with perios- 
titis and infiltration of the soft parts (Parrot's pseudo-paralysis), but it does 
not pass to the shaft, affects principally the upper extremities, and above all it 
appears at the earliest stage — only exceptionally between the seventh and ninth 
months. Simultaneously, as a rule, there are other signs of syphilis. The 
spontaneous fractures of infantile scurvy may resemble simple traumatic frac- 
tures, but the external causes — if such can be demonstrated, are clearly of a 
disproportionately mild nature. Often the sensitiveness and swelling impress 
the physician less than the limitation in movement caused by the pain ; or there 
is an undefined conception of a nervous or of a trophoneurotic disease, and a 
diagnosis is made of hysteria ( ! ) , of cerebral hemiplegia, of infantile paralysis, 
of myelitis. It is unnecessary, however, to call attention to the differential diag- 
nosis from the partial pseudo-paralysis of infantile scurvy. Further, in a con- 
sideration of the pain, neuritis, coxalgia, and a masked disease of the vertebral 
column are suggested. Perhaps the most common confusion is with rheuma- 
tism, but exact investigation will prove that in infantile scurvy the joints, al- 
though at times transitorily fixed, are always uninvolved. Exceptionally — in 
children with severe rachitis — the sensitiveness of infantile scurvy may be con- 
fused with the bone pain of rickets, but in severe, florid rickets the thorax is 
very sensitive, and at the same time the long bones are more or less flexible — a 
condition which is rare in infantile scurvy. Also, in the latter affection the 
swelling of the bones is not marked except at the epiphysis, provided there are 
no infractions with formation of callus. Finally, in so far as the age is not 
against them, there may be confusion with erythema nodosum and with septic 
affections and diseases of the blood (especially leukemia), in which there is a 
tendency to hemorrhage. The diagnosis of renal hemorrhage is especially diffi- 
cult when it occurs as an isolated or principal symptom of infantile scurvy. 
If there are simultaneous periosteal hemorrhages in the legs, the edema which 
appears below, upon the lower leg and the foot, should not be confused with 
nephritic dropsy. If hematuria exists alone, the ordinary bright red, instead 
of brownish, tinge of the urine, the variation in the quantity of blood, the few 
casts and the limited amount of albumin should at least awaken a doubt of a 
renal affection, especially as at this age a causal factor of renal inflammation is 
usually absent. 

It cannot be denied that at the onset and in the abortive types of infantile 
scurvy, as well as with the simultaneous existence of another disease, the diag- 
nosis may be very obscure. From the moment, however, at which the possi- 
bility of this rare affection is presented the picture clears rapidly, for if a 
careful history is taken, especially of the nourishment during the last five 
months, we will know at once whether infantile scurvy need be brought at all 
within the scope of differential consideration. While the examination must be 
very complete, nevertheless, in the interest of the child a certain restraint must 



232 INFANTILE SCURVY (BARLOW'S DISEASE) 

be imposed: Fracture of bones has several times occurred during examination, 
also orbital hemorrhages from crying, due to the pain, which may suddenly 
protrude the eye-ball. Occasionally, after every examination the sleep of 11 le 
succeeding night is disturbed. The sensitiveness of the leg generally indicates 
the diagnosis, and after a careful inspection of those members, and the external 
examination of the remainder of the body, the condition of the internal organs 
must be determined, though usually they reveal nothing of importance: the 
pharynx, mouth, and particularly the gums must be inspected and the tempera- 
ture taken in the rectum. It is often difficult to obtain the urine for purposes 
of examination because of the pain when the child is held. If convulsions are 
present — a rare occurrence — external bleeding of the skull will be found, which 
indicates intracranial hemorrhage. Fortunately, if a positive diagnosis is im- 
possible, the treatment — a complete change of diet — will enable us within a 
very few days to come to a final conclusion. 



TREATMENT 

There is scarcely another affection in which the treatment is so rapidly and 
certainly effectual. In infantile scurvy, in contrast to the epidemic disease, 
the external conditions are always so favorable that the necessary treatment can 
easily be carried out. The first point of importance is to stop the improper 
nutrition: Milk and infant foods might be altogether omitted, but in those 
cases where only the too prolonged boiling of simple cow's milk has been opera- 
tive the degree of heating may be changed. Under some circumstances a cer- 
tain limitation is sufficient : A shorter period of heating in the Soxhlet appa- 
ratus, boiling up two or three times over an open fire when Pasteurized as well 
as cooked in the Soxhlet apparatus, or Pasteurization alone. This change in 
the heating of the milk is sometimes sufficient to produce a cure ; the physician 
must know, however, before giving his orders, whether, as is usual nowadays, 
the milk to be used has been previously warmed in any way in the dairy. To a 
lack of this knowledge was due the only fatal case in my practice. We have 
observed that moderate warming is not always well borne by weak children; 
under such circumstances it is better to bring about a change by the avoidance 
of heat. As a matter of fact the most immediate results are obtained by the 
employment of raw milk. It may be given undiluted in amounts of 800 to 
1,000 grms. daily, slightly warmed. The milk must, however, be obtained from 
healthy cows and must be free of the germs which cause infectious diseases in 
the human being, or that give rise to saprophytic decomposition. Kaw cow's 
milk is commonly taken with great relish — in contrast to the milk previously 
administered — but we must be careful to observe that it is well borne and does 
not cause or increase diarrhea. In addition to the products which are espe- 
cially conducive to health the milk may contain those which are foreign to the 
human body and which would be destroyed by boiling. Thus, after the admin- 
istration of raw milk I saw a severe erythema exudativum multiforme appear. 



TREATMENT 233 

If the milk in its raw state is not borne even when diluted, it should be 
warmed for a short time over an open fire. The addition of the ordinary in- 
fant foods does not hinder the curative process, which is a proof that the incor- 
rect method of heating the milk is the cause of infantile scurvy rather than 
the addition of infant foods. Whether the beneficial result of raw milk is due 
to the absence of the deleterious products of heated milk, or to the introduction 
with the raw milk of antiscorbutic substances, such as citric acid, or perhaps 
to both of these causes, cannot be stated definitely. In favor of the first view 
is the partial or non-success which attends the use of antiscorbutics with simul- 
taneous improper milk feeding. 1 

From the emphasis placed upon the curative effect which is brought about 
b} r the withdrawal of the deleterious food, it is evident that the administration 
of remedies which are specifically antiscorbutic are not necessary in infantile 
scurvy. Nevertheless they may be useful. When there is a constitutional 
change in the blood which is manifested by a tendency to hemorrhage these 
expedients are calculated to bring about an improvement in the tissues. Even 
in a case of congenital hemophilia I saw success follow treatment with lemon 
juice. Just as little as the damage wrought by scurvy to the physical condi- 
tion, and especially to the hematopoietic organs and the blood, can be referred 
to a uniform chemical agent, do the remedies employed for scurvy uniformly 
remove the chemical cause of the affection. The familiar antiscorbutics are of 
various kinds. On the one hand, in addition to milk and honey, there is meat; 
its salts are absolutely without effect; meat-broth can never prevent the develop- 
ment of infantile scurvy nor care it. Probably, therefore, genuine albumin is 
the active principle ; the expressed juice of fresh meat is administered, several 
teaspoonfuls throughout the day, and observation is made as to whether or not 
it is well borne. In contrast to this, eggs are absolutely without effect, although 
they contain abundant genuine albumin and other substances which are essen- 
tial for the growth of the body. 

Of the vegetables, those containing seed are ineffectual, in whatever form 
they are prepared. It is an error, however, to regard green vegetables alone 
as specific antiscorbutic remedies, and to believe that they must be fresh when 
eaten. The active vegetable substances require heat and are found in vegetables 
of the most varied kinds. That we are here dealing in part with vegetable acids 
is shown by the use of lemon and orange juice. Other fruits will act in a 
similar manner, whether raw or cooked, for example, apples, pears, goose- 
berries, whortleberries, strawberries, and the like, peaches, apricots, plums, 
cherries, pineapples, melons and dates. Among the vegetables may be men- 
tioned spinach, carrots, peas, kale. The action of asparagus and cauliflower 
is doubtful. The various salads also come into question — cress, lettuce, green 
salad — and stewed rhubarb. Mashed potato is recognized as a valuable anti- 
scorbutic food. 



1 Case of Finkelstein and other reports in literature. As to the possibility of a 
further view see later! 



234 INFANTILE SCURVY (BARLOW'S DISEASE) 

The action of vegetables is noted only when they are taken in sufficient 
quantity (several teaspoonfuls of the juices, especially lemon and orange juice, 
and at least a small dish of the vegetables) ; the administration of a few tea- 
spoonfuls is not enough to prevent infantile scurvy. 

In place of the food hitherto administered it is well to begin the treatment 
with raw milk or milk heated for a few moments. After one or two days, 
provided there is no diarrhea, diluted lemon or orange juice with a little sugar 
is permitted, and then the vegetables are given, so that the child receives alter- 
nately a small quantity of stewed fruits or vegetables, at first once a day, later 
for two meals of the day. 

While, for many children who have up to this time had only fluid nourish- 
ment, it is necessary to insist upon mixed food, nevertheless, great care must 
be taken to avoid dyspepsia. Particularly when there is vomiting is it neces- 
sary to decide whether the unusual food is the cause, or whether there is a be- 
ginning gastric dyspepsia. 

If at the time of the change in diet diarrhea is present or appears soon 
afterward, it is well to dilute the raw milk with gruel which previously has 
been heated. Of the vegetables, mashed potatoes and the juice of elderberries 
will perhaps be best tolerated. It is not advisable to postpone antiscorbutic 
treatment until a time when the intestinal catarrh will have been cured, aside 
from the fact that an irritation of the colon may itself be due to the scurvy. 
Fixation of the diseased extremities, so long as they are sensitive, is to be 
avoided, and only in the very rare case of marked deviation at the point of 
fracture is it indicated later. While the pain continues all unnecessary move- 
ment of the child, even bathing, is to be avoided. 

No remedy is known that will cure or even favorably influence infantile 
scurvy. This applies particularly to the preparations of iron and phosphorus. 
The swollen gums may be painted with tincture of myrrh. During conval- 
escence there is no objection to the employment of drugs (for example, prepar- 
ations of iron), but I have never employed such remedies, as a suitable nutri- 
tion and the hygiene of the skin, together with plenty of fresh air, have always 
been considered as more essential. 

As was mentioned at the beginning of this article, the recognition of infan- 
tile scurvy must result in its disappearance. In the nutrition of infants all 
excesses in the heating of milk must be avoided, as well as the free substitution 
of milk by artificial preparations. Further, so soon as the teeth appear mixed 
food is imperative. Al though in the treatment of infantile scurvy raw milk 
is advised, for the healthy child milk moderately heated is preferable. If we 
wish to maintain the principle introduced by the Soxhlet apparatus, the milk 
may be Pasteurized for half an hour at a temperature of 60° to 65° C. (140° 
to 149° F.) 1 or it may be boiled slightly over an open fire and then poured 
hot into clean bottles which are protected by Fliigge's glass covers or an alumi- 
num cap; but the cooling should always be rapid and the milk must be kept 

1 For example, in Kobrak's apparatus. 



TREATMENT 235 

cold. After the sixth month mixed feeding should begin in the manner pre- 
viously indicated. How this is best to be extended (eggs and the like) does 
not come within the scope of this article. With a mixed diet the daily quantity 
of milk or milk broth may be limited to one or one and a quarter liters. That 
this form of nutrition is advantageous to the child has been proven satis- 
factorily by experience. [Offensive discharges do not contraindicate the imme- 
diate use of orange juice, on the contrary. Decoctions of oatmeal or barley 
when added to the raw milk act as anti-fermentatives. Open windows, day and 
night, and cold air stimulate a healthy metabolism. The long list of foods rec- 
ommended above is a rather long one for a baby less than a year old. — Editor.] 



RICKETS (RACHITIS) 

By J. ZAPPERT, Vienna 

I. INTRODUCTION. HISTORY 

Rickets is an anomalous constitutional disturbance of early childhood, char- 
acterized by alterations in the growth of the skeleton and recognized by them. 

The term rachitis was introduced by Glisson, who probably discovered a 
relationship therewith of the common curvature of the vertebral column 
(pdxis, vertebral column), but by his use of the single letter r, instead of rh 
he indicated the English popular designation of the affection, rickets. German 
thoroughness, for philologic reasons, decided the use of the word rhachitis, but 
it is not necessary to out-Herod Herod and we have now generally accepted the 
popular spelling with a simple r. 

The common German designation for the affection is "the English dis- 
ease" (first described by English authors) or "double limbs," that is, double 
growth, so-called because of the enlargement of the epiphyses. The French 
designate the affection " rachitisme " by which, perhaps, they express in a 
better manner than by our doubtful term rachitis the constitutional nature of 
the affection rather than an inflammatory process. 

Whether the affection was known to the civilized peoples of antiquity is 
questionable; the quotations in this respect from ancient authors are as little 
convincing as a hump-backed statue of Aesop of the classical period, frequently 
quoted, which much more likely represents recovery from spondylitis. Never- 
theless, it is remarkable that Soranus, in the second century A. D., mentioned 
the occurrence of curved legs in Eoman city children as being more frequent 
than among the country population — a statement which might very well be 
utilized in favor of rachitis. The finding of probable rachitic curved bones 
in Grecian graves has been regarded as evidence of the prevalence of the affec- 
tion in ancient times (Epstein). 

Still more uncertain is our knowledge relative to the presence of the dis- 
ease in the Middle Ages, although we a»re not justified in drawing conclusions 
from the lack of reports during that period of mental apathy. Of interest in 
several respects is a recent report of Stegmann before the Vienna Anthropo- 
logical Society that rachitic, curved bones have been found in the graves of 
South American natives which antedate the time of Columbus. A remark of 
Theodosius in the year 1584 (Stoltzner) certainly has reference to a rickety 
child. 

236 



INTRODUCTION. HISTORY 237 

These and a few isolated early reports of physicians do not alter the fact 
that medical knowledge of the affection dates from the year 1650, at which 
time an English physician, Glisson, published his monograph upon rickets (de 
rachitide sive morbo puerili) which has since become celebrated. The cumu- 
lative appearance of this affection in English districts resulted in a medical 
commission for the study of the affection, the outcome of which was Glisson's 
report. This author gave such a comprehensive description of the affection 
that to him belongs the credit of the first professional observation of the dis- 
ease, notwithstanding some preceding and simultaneous reports of other 
writers. 

The literature of rickets dates back to about 1840. Xew reports followed 
in constantly closer sequence which treated of the entire symptom-complex of 
the disease or of certain portions of it, and in particular its etiology, pathology, 
and treatment. At the present time the reports are so numerous as to exceed 
those of almost every other affection of infancy. Kecent advance in the knowl- 
edge of the disease is associated, among others, with the names of Elsiisser, Vir- 
chow, Bitter v. Eittershain, Kassowitz, Pornmer, Spillmann, and Stoltzner. 
The last author recently published a book on rickets with a compilation of 
about 450 reports — perhaps the most noteworthy work upon the subject in the 
last two centuries — without absolutely exhausting the subject. 

In spite of this extraordinary example of industry, intelligence, observa- 
tion, and reflection we are to-day but little further advanced than we were 
fifty years ago in our knowledge of " the English disease." Rickets has become 
an actual battle-ground for specialists in children's diseases. Scarcely a dis- 
puted question in the great realm has been solved; pathogenesis, anatomy, 
treatment, and even many points in the symptomatology are yet the subjects of 
active and often exciting controversy. When it is seen how results which were 
regarded as positively proven are constantly combated with new arguments; 
how theories, the tenableness of which was declared undoubted, have been dis- 
proved by newer observations; how investigators, who believed that they had 
raised a monument by their researches in this direction, have been overthrown 
by opponents, we must admit that a great amount of labor and thought have 
been devoted to this theme, but we cannot escape the impression that often 
personal factors — rigid adherence to what has once been stated, inherent oppo- 
sition to views set forth by one or the other side — have played a great role in 
the discussion of rickets and have sometimes prevented the objective opinions 
from assuming the importance due them. 

It is to be hoped that a later generation of physicians will succeed in clear- 
ing this well-cultivated but bewildering field of labor, and bring to a finale this 
extraordinarily interesting chapter of rickets. 



238 RICKETS (RACHITIS) 



II. DISTRIBUTION, FREQUENCY, INFLUENCE OF SEASON 

I. DISTRIBUTION 

There has long been a definite knowledge of the extraordinary distribution 
of rickets in all countries of the temperate zone (Hirsch). The only uncer- 
tainty related to its occurrence in northern countries, upon certain islands, in 
highly mountainous regions, and in the tropics ; but a careful investigation in 
such localities has yielded positive and increasing results. Thus Johannessen 
found numerous cases in Norway (Christiania), Feer met with the disease in 
the high valleys of Switzerland, Kassowitz in the Tyrol ; Fede found as many 
rickety children in Naples as in Northern Italy; in Sicily (Palermo) there is 
an institution for rachitics. Monti diagnosticated rickets in Japanese children, 
four years of age, who had immigrated into Germany ; Stoltzner found the dis- 
ease in mulatto children (in Berlin) ; Palgrave saw it in Arabia; Moncorvo 
found numerous cases in Rio de Janeiro, among the blacks as well as in the 
white population. Under these circumstances it is a question whether the re- 
ports in regard to the immunity of certain regions, which are often based on 
general observation, especially of children who can creep and walk, will not re- 
quire correction after an exact study of infants and the adoption of the usual 
diagnostic measures. Some thoroughly competent observers, however, have 
stated that Iceland, the Faroe and Ionian islands, Roumania, Turkey, Algiers, 
Mexico, Peru, China, Japan, India, Java, Canada, etc., may be regarded as 
free from rickets, that is, regions in which few cases occur. 

That racial peculiarities also play a role, as is generally assumed, has not 
been positively proven. It is true that the Caucasian race in general shows a 
particularly marked predisposition, but since investigations in this direction 
have demonstrated the presence of rickets in negroes and in Mongolians, it is 
questionable whether an accurate research will not show merely a simulated 
preference for the white race, that is, that a residence in large cities explains 
the condition. The racial influence and the cumulative effect which are shown 
among the immigrant Italians of North America (Snow) may also have their 
explanation in the great poverty which exists among this portion of the popu- 
lation. The immunity from the English disease which is maintained among 
Gipsies, Kirghiz, and Kabyles demands an investigation of their offspring. 

Notwithstanding these skeptical remarks the possible and even probable 
immunity from rickets in certain races and countries is by no means to be de- 
nied. From the importance which is given, perhaps justly, to heredity (see 
below) it might readily be thought that in some people under favorable circum- 
stances (mode of living, residence in the open air, etc.) the appearance of 
rickets could be prevented; that by enforced surroundings (islands, moun- 
tains) or social relations (Gipsies, Turks, etc.) an inbreeding may have trans- 
mitted this immunity further, so that even to-day these races have almost no 
rachitic children. Perhaps rickets will be a valuable example in the highly 



DISTRIBUTION, FREQUENCY, INFLUENCE OF SEASON 239 

interesting problem of the importance for the health of the people of inbreed- 
ing and mixed marriages. 

II. FREQUENCY 

Somewhat more uniform are the views concerning the frequency of rickets 
in the regions in which it exists. Kassowitz calculates that 89 per cent, of 
the children of his out-patient service in Vienna are rachitics. Epstein gives 
about the same figures for Prague and Kissel for Moscow. Jouconsky calcu- 
lates about 90 per cent, for St. Petersburg (Baumel), while another author 
mentions only 32 per cent, for the same city. Mey found 80 per cent, in Riga. 
In London, according to Baumel, 92 per cent, of artificially-fed children under 
one year are rachitic. In Berlin, according to Cohn, 65 per cent., according 
to Hauchecorne and Stoltzner, 90 to 95 per cent. In German cities, among 
other reports there are those of Munich (Seitz), 72 per cent., Frankfort 
(Rehn), 50 to 60 per cent. Of the French reports those of Chaumier (Tours) 
show 50 per cent., of Baumel (Montpellier), to whom we are indebted for a 
comprehensive compilation of these figures, 50 to 60 per cent., while Marfan 
calculates about one-third of the population of Paris to be rachitic. In Basel 
Feer has estimated 86 per cent., Johannessen in Christiania 66 per cent, Fede 
in Naples 50 per cent., and Moncorvo in Rio de Janeiro 50 to 80 per cent. 

From these figures it appears that the English disease is very common in 
various cities of Europe, The variations in the above figures preclude a posi- 
tive deduction as to the unequal frequency, for the figures of some authors are 
taken entirely from hospitals, others cover only definite periods. Further, 
many dispensaries (for instance that of Kassowitz in Vienna) are especially 
frequented by rachitic children; therefore Mey's idea to include only vacci- 
nated cases appears advisable. Some of these differences in the figures may 
be due also to the various diagnostic view-points, whereby one investigator may 
assume rickets where another will note nothing abnormal. Finally, the ques- 
tion of frequency, as well as of the distribution of the disease, rests largely 
upon the exactness with which the clinical material is studied. The admitted 
errors of certain authors are very instructive. Thus, Fishchl, in the reports 
of the Munich Children's Clinic mentioned only 5.1 per cent, of rachitic cases, 
whereas Seitz, by a careful investigation of the same clinical material (chil- 
dren under one year), was able to find 72 per cent. Baumel calculated the 
number of rachitics in Montpellier to be 4 per cent, but was obliged to increase 
the figure to over 50 per cent, when the question was more closely studied for 
the purpose of a paper before the Moscow Congress. A similar error was expe- 
rienced by Feer in Basel. Lange reports that in the same region of Saxony 
one physician had estimated 2 per cent., another 50 per cent, of rickety chil- 
dren under one year of age. These figures show conclusively how the accuracy 
of the reports regarding the distribution and frequency of the disease is de- 
pendent upon the precision of physicians who have made a specialty of chil- 
dren's diseases, and how little the approximate figures and general conclusions 
signify. 



240 RICKETS (RACHITIS) 

Rickets occurs principally in the crowded quarters of large towns. It is 
more common among children of cities than of the country; but even in the 
affluent classes it is by no means rare. Kassowitz found rickets in 89 per cent, 
of his charity patients and 59 per cent, among his prosperous clientelle, but 
the well-to-do classes are more exempt from the severe forms of the affection, 
and particularly from the continuance of the disease after the second year of 
life — due unquestionably to favorable hygienic conditions. 

Whether climate is an influential factor in rickets is doubtful. Hagen- 
Torn has attempted to prove by careful examination that the affection is con- 
fined to regions of great humidity (80 per cent.), but Shukowsky has quite 
properly suggested that in moist climates children are confined to the house 
more than in dry regions, therefore moisture has only a mediate influence upon 
the appearance of rickets. 

On the other hand it is unquestionable that absence of air and light and 
the lack of an open air life exert an unfavorable influence upon an existing 
predisposition, i. e., upon the course of the affection. This may explain the 
relative rarity of rickets among the rural population in the warmer climates 
and high valleys with powerful winter sun (Davos), and the cure of rachitic 
patients in the country, at the seaside, or in the mountains. Keller main- 
tains that in houses which are shaded he has found more cases of rickets than 
in those exposed to sunlight (Feer). From this, however, it must not be con- 
cluded that the " mountain air," as such, gives immunity from rickets, as 
Feer was able to demonstrate the affection comparatively often in manufac- 
turing districts of dense population and high altitude, while secluded villages 
at the same elevation showed very few cases. The fact that people who have 
immigrated from the plains into high valleys bring up more rachitic children 
than the endogenous population (Feer) also gives rise to thought and enjoins 
us not to overlook the importance of hereditary immunity in the subject of 
favorable climatic conditions. 

in. SEASON 

An important argument for the unfavorable influence of indoor life, as 
demonstrated by Kassowitz, is the season curve of rickets. 

According to several reports ( Klein- Schwechten, Wallach, Alexander, 
Quisling, Feer, Mey, etc.) it is evident that the number of rachitics who flood 
the dispensary in children's hospitals in the early months of the year (Feb- 
ruary, March, April) is much greater than in the summer and in the autumn. 
The rachitic curve, therefore, has a rapid ascent in the spring and a descent 
in the summer. 

The cause of this rachitic curve is questionable. Kassowitz bases upon it 
his " respiratory theory," according to which the deleterious effects of winter 
residence in poorly ventilated rooms is said to be the actual cause of rickets 
during this season. But Lange quite properly objects to this, for the reason 
that the ascent of the frequency curve of rickets in the spring in the out- 
patient service may also be due to other causes — associated bronchitis; possi- 



AGE OF ONSET. CONGENITAL RICKETS 241 

bly because they are more in the open air. We will content ourselves with the 
fact that Kassowitz' explanation of the rachitic curve is true of the ambulatory 
patients of the hospitals of large cities, without seeking for further con- 
clusions. 

It would be of more interest to know whether, as Seitz believes, more 
rachitic children are horn in the spring than in the autumn, or whether the 
reports of Bystrow and Pavone (quoted by Monti) that children born in the 
autumn are more frequently attacked by rickets than those born in the sum- 
mer, could be confirmed by investigation in children of the prosperous classes. 
At present this theoretically important question is unsettled. 



III. AGE OF ONSET. CONGENITAL RICKETS 

7s rickets a congenital disease ? The answer to this question is of cardinal 
importance for the pathogenesis of the affection. All theories relative to dis- 
turbances of metabolism, respiratory and other deleterious factors are of sec- 
ondary consideration and, in a part of the cases at least, would be transferred 
from the child to the mother if it is true that rickets is a congenital disease. 
Unfortunately there are vast differences of opinion concerning this which 
make a decision difficult. 

The marked anomalies of the skeleton which are now and then found in 
the new-born, and which are designated fetal rickets, must be left out of dis- 
cussion. These congenital deformities have nothing in common with rickets 
and had better be designated by another term (osteogenesis imperfecta or osteo- 
porosis congenita, chondro-dystrophia or fetal myxedema) than to confound 
the condition by intimating a relation to rickets. 

The arguments in favor of actual congenital rickets may be covered by 
three questions: 1. Are there in the new-born distinct clinical evidences of 
rickets ? 2. Are the rachitic diseases of the bones of the new-born to be con- 
sidered histologically rachitic? 3. Does a case of undoubted rickets develop 
from the rachitic symptoms of the new-born? 

1. The occurrence in the new-born of clinical symptoms, seemingly rachitic, 
has been demonstrated by a number of investigators. Such symptoms are 
craniotabes, large fontanelles, and the rosary. After the expressed views of 
older authors in this direction (Elsasser, Bednar, v. Eitter) Kassowitz demon- 
strated rickets in premature infants and in the children born at term. Unruh 
confirmed this and assumed the congenital nature of all cases of rickets. 
Schwarz, in Vienna, found nearly 80 per cent, of 500 infants, born in the 
Vienna Lying-in Hospital, to be rachitic. Feyerabend, in Konigsberg, esti- 
mates the number to be about 70 per cent. Quisling, in Christiania, whose sta- 
tistics as to the frequency of rickets are below the average, was able to demon- 
strate 11.5 per cent, rachitic cases among 200 new-born. Feer reported 63 cases 
of rickets among 100 new-born in the Basel Women's Clinic. H. Neumann is 
also an adherent to the theory of congenital rickets, while Heubner is a strong 
17 



242 RICKETS (RACHITIS) 

opponent. Some authors call attention to the high rachitic figures for the first 
weeks of life, which might be considered to indicate an intrauterine onset of 
the affection (M. Cohn, Kassowitz). Therefore, in regard to the clinical 
symptoms there is, with but few exceptions, a unanimous opinion as to the 
occurrence of congenital rickets. After comprehensive investigations I have 
reached a similar conclusion, but would attach greater diagnostic value to the 
softness of the occiput than to other anomalies of the skeleton. 

2. Anatomical researches relative to congenital rickets are few. After the 
individual observations of Virchow, Mori, and Borntrager, Kassowitz, upon 
the basis of histologic examinations of the bones of new-born infants and of 
children of premature birth, firmly maintained that rachitic changes could 
very frequently be demonstrated (in 2G among 29 cases). A number of sub- 
sequent investigators, as Fede, Lenz, Tschistowitsch, and more recently Escher, 
have failed to confirm these lesions. The last-named author was unable to 
find any clinical symptoms of rickets in 105 children examined by him, since 
he denies that flexibility of the cranial bones at the margin of the sutures and 
distinct prominence of the epiphyseal boundary of the ribs are rachitic phe- 
nomena. Had he thought otherwise he would, like Schwarz and others, have 
found 80 per cent, of his patients rachitic. Kassowitz's view is confirmed by 
Fischl, who proved histologically that the prominence upon the cartilage of the 
ribs in the new-born were the signs of rickets. 

Here apparently there is an insurmountable contrast between adherents and 
opponents of the intra-uterine origin of rickets, which depends entirely upon 
the interpretation of anatomical specimens. 

Our knowledge does not justify a decision as to whether Kassowitz's find- 
ings or those of his opponents are the correct ones. In any event the stage 
of onset of rickets is exceedingly obscure, and anatomical researches, which 
might illumine the subject, are limited. Our decision becomes all the more 
difficult if only the bones of the skull are examined, the softness of which is 
conclusive in the diagnosis of congenital rickets. The uncertainty of the 
findings in the histologic preparation is made obvious by a remark of Fischl 
to the effect that Tschistowitsch's findings, which are interpreted as being 
opposed to congenital rickets, " completely coincide with the histologic pic- 
ture which Spillman outlines of the initial stage of the disease." 

3. Light is shed upon this obscure realm by a recent work of Spietschka 
in Prague. After M. Cohn had demonstrated that from insignificant rachitic 
symptoms in the new-born distinct rickets arises later, Spietschka again inves- 
tigated the subject in a large number of cases in Epstein's Foundling Asylum 
at Prague, with very decisive results : 

In all those children, who, a few days old, were transferred from the Mater- 
nity Department to the Foundling Hospital with symptoms which were mani- 
festly rachitic, the symptoms increased during several months of observation 
to well developed rickets, which was only controlled by treatment with phos- 
phorus. The percentage of children born with rickets is estimated by 
Spietschka to be 50 per cent, (in 1,468 cases). 



AGE OF ONSET. CONGENITAL RICKETS 243 

The author arrives at the following conclusions : " The softness of the 
occiput (craniotabes), the so-called defective ossification of the skull, the gap- 
ing sutures and their flexible margins, the disproportion between the circum- 
ference of the head and of the thorax in the new-born child, yield at once to 
that transformation which in the other child is generally recognized as the 
typical rachitic skull. As a rule, when these cranial phenomena appear in the 
new-born the remainder of the skeleton undergoes a rapid change. These 
peculiarities of the skull in the new-born child therefore represent the first 
symptoms of rickets. Accordingly there is a congenital rachitis. Most cases 
of rachitis are congenital/' 

There can scarcely be any objection to this method of proof provided we 
do not wish to transfer the diagnosis of rickets from the sick-bed to the post 
mortem room. Fischl quite properly emphasizes that for a diagnosis of rickets 
in the new-born not only the bony changes but the entire habitus, especially 
the distended abdomen, require consideration. 

If, after what has been stated, the pros and cons of the intra-uterine 
development of rickets are weighed, we must admit that the clinical evidence 
on both sides is so overwhelming that, so long as the onset of the rachitic 
bony changes is not absolutely clear, the question cannot be decided by patho- 
logical anatomy alone. 

Nevertheless, the occurrence of congenital rickets is very probable, and the 
possibility must be considered that every case of rickets arises from a congenital 
basis, and that external circumstances probably favor the development of 
rachitic symptoms, but do not produce them. Unruh, Feer, and Spietschka 
are more or less acknowledged adherents of this view, although the last two, 
from their statistics, only maintain that rickets " usually develops intrau- 
terine." It will scarcely be possible to solve this puzzle by means of figures. 
We will always find infants in whom, on account of its insidious development, 
no clinical symptoms of rickets can be demonstrated, and so long as the dis- 
ease of the bone is the decisive diagnostic criterion it will be impossible to 
decide whether or not a constitutional predisposition or a dyscrasia prevailed 
before the appearance of the skeletal anomalies. Finally, analogous to certain 
positive congenital nervous diseases which do not appear until later in life, 
we cannot deny a congenital predisposition to rickets beyond the age of infancy. 
However, we will not pursue this purely hypothetical theme further, as a too 
great generalization might destroy the foundation of those cases of rickets in 
which the intra-uterine origin appears to be certain. 

On the contrary, according to clinical experience, we must maintain that, 
in addition to congenital, there is an acquired form of rickets in which the 
symptoms develop under observation. 

Eeports concerning the age of greatest frequency vary according to the 
views of different authors as to the intra-uterine onset of rickets. 

Baginsky, an opponent of congenital rickets, never saw the affection in 
children younger than three months, and considers the period of acme to be 
between the twelfth and eighteenth months. Guerin and others name similar 



244 RICKETS (RACHITIS) 

ages. Anders maintains that florid rickets belongs to the second year of life 
(Mey). In contrast to this Ritter remarks that rickets is most frequent in 
the first year of life, and that then one-third of the cases are observed during 
the first six months. Kassowitz also has noted the majority of the cases in 
children under one year. The following instructive table is given by M. 
Cohn: 

0- 6 months 62.8 per cent, rachitic, 

7-12 " 66 " " 

1-1£ years 72.1 " 

12-2 " 70.6 " 

2-3 " 61.6 " 

From this it is seen that the frequency of rickets gradually increases in 
the first years of life and that the disease is actually most common in children 
aged one year or a year and a half. Contradictory reports like those of Bagin- 
sky, who saw no case in children under three months, and of M. Cohn, who 
in the first six months found rickets in 60 per cent, can only be explained by 
variations in the diagnostic view-points which permit one author to utilize 
changes to which the other attaches no significance. 

Rachitis tarda, i. e. ? the appearance of florid rickets in children four or 
five years of age, has been described by many writers (Biedert, Gartner, v. 
Genser, James, Duplay, Hutinel, Aucher, Knopf elmacher, and others). In 
this category also those cases of typical rachitis must be included which had 
existed in early infancy and had been cured prior to a reappearance of the 
disease. 

In how far curvature or flexibility of the bones at the age of puberty and 
later (flat-foot, etc.) have to do with rickets cannot be discussed here. 

The rachitic bony changes of the skull, the pelvis, the extremities, etc., 
which are noted in the adult do not belong to this affection as such, but are the 
remains of a process which occurred in infancy, and may be designated rickets 
as little as macula cornea? may be termed a scrofulous inflammation of the 
eyes. 

IV. HEREDITY 

The fact that rachitis may often develop intra-uterine is not equivalent to 
heredity. Congenital rickets may be acquired intra-uterine but need not there- 
fore be inherited. Also, from the colossal distribution of rachitis among the 
children of large cities, the conclusion may be drawn with some basis of cer- 
tainty that the disease was widespread in the previous generation, and that, 
therefore, undoubtedly a descent of rachitic children from parents who had 
been rachitic can be statistically proven; but this cannot be utilized as a proof 
of undoubted heredity. It would still remain questionable, however, whether 
rachitic children are in fact the offspring of parents who have suffered from the 
same affection, and, if this is the case, whether external conditions have not 
brought about the development of the disease in the mother as well as in the 
child. 



VIEWS REGARDING THE ETIOLOGY OF RACHITIS 245 

Undoubtedly these are the reasons which have led authors to omit from dis- 
cussion this problem of rachitis, and to report only individual observations. 
Thus Feer found that mothers with rachitic residues, even when they subse- 
quently dwell in regions free of rickets, bear children with the English disease. 
Elgood knew of a woman who had children by three husbands; only the chil- 
dren of the father who showed distinct remains of rickets were rachitic. Sie- 
gert, after some comprehensive studies, has lately approached the question 
somewhat more closely. He reported observations, covering several years, of 
families of which the mothers in some instances were affected by rickets and 
others were free of the disease. He found that as a rule all of the children 
of the former suffered from rickets, while the offspring of healthy mothers 
were usually exempt. He determined also that the manner of feeding of the 
children, as well as the usually unfavorable surroundings, had no decided influ- 
ence upon the affection, although breast-feeding, while it did not prevent the 
appearance of rachitis in children hereditarily predisposed nevertheless ex- 
cluded the severe forms. The period of breast-feeding is also without influ- 
ence on the development of rickets. Siegert, with great certainty and conse- 
quence, maintains the heredity of rickets, upon which other factors are more 
or less dependent. His evidence is not convincing in all particulars, but his 
conclusions coincide with many practical experiences and force the problem 
of heredity in the English disease into the foreground. 

At all events the heredity of rickets, the congenital occurrence, and the 
racial immunity unite in a triad of facts which, if their entity could be estab- 
lished, would be of the greatest significance in the pathogenesis of this affection. 



V. VIEWS REGARDING THE ETIOLOGY OF RACHITIS 

Although in the foregoing the significance of heredity and of the congenital 
origin of rickets has been especially emphasized, this does not justify a rejec- 
tion of the many theories in explanation of the occurrence of the affection. 
Neither of these factors have been positively demonstrated and a vast number 
of cases remain which must be regarded as acquired ; furthermore some of the 
forebears of a rachitic generation must have contracted the malady. Finally, 
in the majority of these patients undoubtedly the acme of the disease is reached 
in the first year of life or later ; therefore even the strictest adherent of heredity 
and of the congenital onset must assume unfavorable extra-uterine influences 
in the etiology. 

As a matter of fact, the number of theories regarding rickets, and the labor 
expended upon them, is enormous, yet no one of them can be considered as 
at all adequate. 

In general the hypotheses are based on the following conditions: Insuffi- 
cient lime metabolism and nutritive disturbances ; acid intoxication; deleterious 
respiratory influences; infectious factors; anomalies of an internal secretion. 

I. Nutritive hypotheses: A. One of the oldest and perhaps most dis- 



246 RICKETS (RACHITIS) 

cussed theories of rickets is thai which assumes as the cause of the affection 

a damage to lime metabolism. 

a) As deficiency of lime in florid rachitic bones is unquestioned, it was 
first assumed that in children who become rachitic too little calcium was pres- 
ent. The main support for this theory was obtained by animal experiment, 
in which softness of the bones was produced through a deficient supply of lime. 
But examination of the milk of the nurses, both of rachitic and non-rachitic 
infants, showed that in either case the amount of lime is the same. It has 
also been demonstrated that cow's milk is much richer in calcium than human 
milk; nevertheless artificially nourished children are more liable to the English 
disease than breast-fed infants. Even if we take into account the precipita- 
tion of a part of the lime in sterilization, a surplus of calcium is still ingested 
by the child (Marfan). Only with permanent and exclusive feeding with 
infant foods (without milk) is a deficit in lime possible, but in most coun- 
tries this form of nourishment, in contrast to feeding with cow's milk, does 
not play a practically important role. A deficient ingestion of lime, therefore, 
cannot be considered in the pathogenesis of rickets. 

b) If, therefore, insufficient lime is not the cause of rickets, the adherents 
of the calcium theory conclude that lime is not sufficiently absorbed, so that the 
blood and consequently also the bones are deficient in calcium. This want of 
absorption is accounted for in several ways. Some authors (Seemann, Zander) 
regard a lack of hydrochloric acid in the stomach as the cause of insufficient 
solution and absorption of lime. This would also explain the frequent diges- 
tive disturbances in rachitic children. The apparent deficiency of hydro- 
chloric acid, however, was not confirmed by the subsequent investigations of 
other authors (Bouchard, Labbe and Klecinsky). On the other hand, Zweifel 
assumed that the calcium assimilated in a soluble form becomes insoluble in 
the intestine and so leaves the structure — a view which was disproven by Soxh- 
let. We are indebted to Riidel and Rey for the experiment which decided this 
question. Following Yierordt's initiative, and having previously determined 
a uniform calcium metabolism, these investigators gave to children who were 
rachitic, and also to those who were free of the affection, a single dose of chalk ; 
both groups of cases reacted promptly and uniformly by an increased excre- 
tion of lime. 

This experiment proved that calcium is just as rapidly and readily absorbed 
in the English disease as under normal conditions and, therefore, that the 
cause of rickets is not to be found here. 

c) Finally, it was thought that while the lime was ingested and assimilated 
in sufficient quantity, an excess was excreted, and this was due to a surplus 
of acid in the blood which dissolves the lime in the bone and permits it to 
pass off from the body. This view of an acid intoxication, for which lactic 
acid particularly was held accountable (Monti), 1 may be positively abandoned, 
according to the experiments of Stoltzner alone and in conjunction with Bru- 

1 C. Heitzmann. — Editor. 



VIEWS REGARDING THE ETIOLOGY OF RACHITIS 247 

bacher. These investigators proved a normal alkalinity of the blood of the 
rachitic child, on the one hand, and on the other that the blood and the soft 
parts in rachitic subjects were not relatively rich in lime, as would be the case 
if the lime were absorbed from the bone. 

It is true that some researches (Babeau) have proved it likely that in cer- 
tain stages of rickets more calcium is excreted than under normal circum- 
stances. This finds its explanation in the fact that calcium salts which have 
been separated from the bone pass off from the body ; therefore we are dealing 
with a consequence, but not with the cause, of rickets (Fischl). 

The main support for the lime theory was obtained from animal expert- 
merits. By feeding animals with fodder poor in lime, simultaneously with 
doses of lactic acid, a softness of the bones was produced (Roloff, Baginsky, 
Voit) . Many objections to the interpretation of these experiments were raised. 
This method probably gives rise to a general decrease in lime but not to a 
selective decalcification of the bones. Besides, the character of the osseous 
changes produced in the animal experiment is by no means histologically iden- 
tical with the rachitic changes, but corresponds, according to Miwa and Stoltz- 
ner, to an osteoporosis which has nothing in common with rickets. Pf aundler 
has reached the same result by chemical experiments, namely, that the absorp- 
tion of lime, introduced artificially into the tissues of animals through the 
vessels, increases the supply of calcium, which is not the case in rickets. 

Therefore, there is overwhelming experimental evidence to oppose the view 
of a relationship of lime metabolism with rickets, and, although Zweifel has 
recently attempted to revive the theory by new arguments, it has been ulti- 
mately rejected by the majority of pediatrists. 

B. The hypothesis of Delcourt, according to which potatoes and milk — 
the food of the poor — produce an excessive secretion of potassium salts in the 
body, thereby preventing sodium combinations in the bones, has found no 
confirmation among other authors (Wedensky, Spillmann). 

C. Those views which regarded digestive disturbances, as such, i. e., the 
absorption of toxic substances from the intestine, as responsible for the develop- 
ment of rickets, were not much more successful. Spillmann, a prominent au- 
thority in the realm of rickets, has recently become an advocate of this hypoth- 
esis, but his single positive animal experiment (production of rickets by 
subcutaneous injection of the intestinal contents), when contrasted with the 
number of negative results, does not warrant such far-reaching conclusions. 
In any event, clinical experience is opposed to the theory, for certainly there 
are many rachitics who never have suffered from decided digestive disturb- 
ances, and accordingly the inclusion of intestinal disturbances among the 
initial symptoms of rickets becomes untenable. 

Nevertheless, repeated experience, lately increased by Siegert's report, 
shows that there is a greater frequency of rickets, as well as a more severe affec- 
tion, in artificially-fed infants than in those ivlio are breast-fed, and the ques- 
tion remains whether unfavorable hygienic influences, poor nourishment, or a 
specific action of the food is the cause. 



248 RICKETS (RACHITIS) 

II. The influence of unhygienic conditions, especially unsanitary habita- 
tions, has suggested to Kassowitz the theory of deleterious respiratory influences 
for the pathogenesis of rickets. He believes that the life of children in unven- 
tilated rooms, the inhalation of foul air ("odor of the poor"), plays a domi- 
nant role in the etiology of rickets, and bases this view particularly upon the 
ascent of the rachitic curve after the winter months. 

Although this theory includes some undisputable facts and claims a number 
of adherents, it is little more than a paraphrase of the statement that greater 
numbers of rickety children come under observation after the long confinement 
in rooms during the winter. Which of the deleterious agents that are com- 
mon in the destitute population, as poor ventilation, improper food, lack of 
cleanliness, neglected disease, etc., is the principal factor is by no means obvi- 
ous. The respiratory theory of rickets, therefore, is a figurative expression of 
an observation, but can scarcely be regarded as an etiologic hypothesis. 

A more precise, scientific form was given to this theory by Wachsmuth, 
who assumes that in ill-ventilated rooms there is a surplus of carbonic acid 
which results in a surcharge of the blood. This excess of carbonic acid in the 
blood causes a greater solution of lime salts, and, by hindering the physiologic 
activity of the cartilage-cell, produces a splitting of lime in the bone. The 
deleterious product circulating in the blood also produces a contraction of the 
arteries and a consecutive hyperemia of the capillaries which prevent the carti- 
lage-cell from reaching that stage of maturity consistent with its complete 
chemical activity. In consequence of digestive disorders there may also be a 
decomposition of the excess of lactic acid which leads to the production of 
carbonic acid in the intestine and its transmission thence into the blood. The 
result is then the same as in the respiratory excess of carbonic acid. While 
this theory of Wachsmuth's might satisfy our casual requirement, it will not 
bear close investigation. The occurrence of rickets in children who are well 
cared for and well nourished, its absence in cyanotic children with congenital 
disease of the heart (Edlefsen), and finally, the proof of normal alkalinity of 
the blood in rachitis (Stoltzner) have deprived the theory of its support, so 
that it remains only the hypothesis of a philosopher. 

III. Rachitis has recently been included by some celebrated authors among 
the infectious diseases (Hagenbach-Burghardt, Edlefsen, Chaumier, Vierordt, 
Sterling). In support of this view the cumulation of rickets in certain streets 
and houses, its limited geographic distribution, the enlarged spleen, the analogy 
of the season curve with that of some infectious disease (pneumonia, poly- 
arthritis), its preference for the osseous system whereby it resembles certain 
other infectious diseases of childhood, have been invoked. Nor did we have 
to wait long for the finding of bacteria in the bones of rachitics (Mircoli) 
which actually appeared to confirm this hypothesis. But active opponents 
have not been lacking and to some extent they are justified (Kassowitz, Fischl). 
The cumulative appearance of rickets in certain quarters of a large city, and 
its geographic distribution, find explanation in unhygienic conditions, racial 
peculiarities, and heredity (see above). The massing of the affection in cer- 



VIEWS REGARDING THE ETIOLOGY OF RACHITIS 249 

tain houses is scarcely surprising, for we are dealing with the slums, and the 
children crowded into these districts have 80 per cent, of likelihood to con- 
tract the disease. The analogy of the season curve of rickets and other dis- 
eases has not been definitely proven; as explained above, the increase in the 
former does not necessarily indicate an actual frequency, and there is never an 
occasional cumulative appearance in other seasons, as is the case in other infec- 
tions. Enlargement of the spleen is not a regular accompaniment of rickets 
(see below) and need not necessarily signify an infectious disease. Fever 
does not belong to the symptom-picture of rickets but is due to complications 
(see below). The analogy with other infectious diseases of the osseous system 
in infancy (syphilis, scrofulosis) loses its significance if we consider that, at 
this age particularly, the bones are the regions of active blood circulation and 
of growth, and if we further consider other non-infectious conditions of infancy 
which markedly involve the skeleton (myxedema, chondrodystrophia). Fi- 
nally, according to Spillmann's subsequent comprehensive researches and ex- 
periments, the positive bacteriologic findings may be regarded as accidental 
contaminations. 

Therefore, the etiology of rickets cannot be determined from these consid- 
erations, as it is impossible to decide whether arguments or counter-arguments 
are the more weighty. It would seem, however, that the evidence in favor of 
an infectious or miasmatic origin is outweighed by proofs to the contrary, 

Oppenheimer's hypothesis that malaria always precedes rickets, and 
Parrot's theory of a preceding hereditary syphilis, are merely of historic 
interest. 

IV. The most modern phase in the etiology of rickets is Stoltzner's theory 
of a functional disturbance of an organ with internal secretion. Other authors 
have held similar views: Thus, Knopf elmacher and Heubner, who fed the 
thyroid gland to rachitic children, and Mettenheimer and Mendel, who fed 
the thymus gland. Stoltzner has included the suprarenal gland in the circle 
of his considerations and has attempted therapeutic researches. None of these 
procedures, however, has furnished convincing results and therefore cannot 
be utilized from the standpoint of treatment. Nevertheless, there is an 
encouraging thought in this idea which perhaps will have a beneficent influ- 
ence in the question of the etiology of rickets. For example, the analogy with 
myxedema, which Stoltzner suggests, is noteworthy and might explain the con- 
genital appearance, the hereditary influence, and the geographic and ethno- 
graphic distribution of rickets. It does not seem necessary to assume infec- 
tious-endemic causes to be responsible for the absence of function of the organs 
in question, as does Stoltzner, since they have not yet been proven for endemic 
cretinism. We might much more assume a hereditary predisposition, .per- 
chance like the uric acid diathesis, wherein, as previously mentioned, the inter- 
marriage of afflicted individuals furthers the appearance of the English disease 
in the descendants; that parents from, a rachitic-free stock would generate an 
apparent immunity in their children and in the race. It is true, external influ- 
ences would also have to be operative to produce rickets in one predisposed child 



250 RICKETS (RACHITIS) 

while another is exempt. The question still remains, what factors are first 
active in families previously free of the disease. 

In this sense, even if we assume the correctness of the last theory, the 
importance of nutrition and of the environment of the child would be worthy 
of further study as regards the pathogenesis of rickets. 

VI. SYMPTOMATOLOGY AND DIAGNOSIS 

Some authors describe prodromal symptoms of rickets. By this they desig- 
nate either disturbances in the respiratory and digestive organs, which are 
also regarded as the cause of the disease, or nervous irritability, sweating of the 
head, and sleeplessness. 

I cannot agree with either of these views. Diseases of the respiratory and 
digestive tracts, as will be explained later, are not inevitable accompanying 
conditions, much less the precursors of the English disease; and the nervous 
manifestations, if due at all to rickets, are not prodromes but accompanying 
phenomena, the affection being already apparent by a softness of the occiput. 

In a malady so eminently insidious as rickets we can as little determine the 
time of onset as of cure, but we must not forget that pathologic processes have 
existed in the body prior to the appearance of changes in the skeleton, although 
their recognition was at the time impossible. 

Symptoms actually characteristic of rickets, and not occurring in any other 
disease, are furnished by the osseous system alone, the lesions of which must 
naturally occupy the greatest part of the discussion of the symptomatology. 

First we shall describe those symptoms which might be regarded as the 
criteria of congenital rickets. The earliest lesions are found in the bones of the 
head. The sutures of the skull, especially the sagittal suture, are gaping, the 
edges of the frontal fontanelle and the sutures are soft and yielding, the 
posterior fontanelle is not completely ossified, upon the back of the head and 
in other portions of the skull there are soft, parchment-like areas. Sometimes 
the greater portion of the tabular part of the occipital bone is not firm in con- 
sistance and yields to pressure of the finger. Such a change of the skull is 
found in children who are normal at birth, as is shown by their habitus and 
weight, as well as in premature infants. Inversely, premature children may be 
born with a perfectly hard occiput. Besides these characteristic cranial phe- 
nomena of congenital rickets there are secondary osseous changes. The costo- 
chondral borders are thickened, but even normally there is a slight bead-like 
prominence, so that the transition from a normal to a pathologic condition is 
extremely difficult to define. Likewise, curvature of the tibia and the " rachitic 
habitus " of the new-born, made prominent by Fischl — distended abdomen, 
thick-set thorax with broad base — are not present in all cases of congenital 
rickets. 

The symptomatology of " acquired " rickets, which arises after birth, is 
more distinct. The disease then shows itself most prominently in those por- 
tions of the skeleton which are undergoing the greatest development. This 



SYMPTOMATOLOGY AND DIAGNOSIS 251 

gives to the sequence of rachitic symptoms a certain degree of regularity that 
varies according to the period of onset. 

The greater number of cases of acquired rickets develop in the first half 
year (often in the first three months), with softness of the occiput which 
Elsasser has well defined as craniotabes. Notwithstanding the fact that its 
relation to the English disease was for some time in doubt, it is one of the 
earliest and most distinct symptoms of acquired as well as of congenital rickets. 
If the skull of the infant is examined in the recumbent posture, with the head 
grasped in both hands, palpation of the occiput in the region of the posterior 
fontanelle, at the occipital suture as well as in the dependent portions of the 
parietal bones, will reveal the presence of craniotabes in the form of a few soft 
areas which yield to the pressure of the finger like a fully distended bladder. 
This softness of the posterior skull, often only of the size of a cent or of a 
quarter dollar, is sometimes of such wide circumference that only the pro- 
tuberantia occipitalis and its surroundings are uninvolved. The soft, yielding 
occiput becomes flattened by the constant recumbency of the child, and the hair 
upon this part of the head, which is scant even under normal circumstances, is 
almost worn off. A very common accompanying symptom of craniotabes is 
sweating of the head, particularly of the posterior portion, and after the child 
has been asleep for some hours the pillow may be saturated. Whether the soft- 
ness of the occiput causes pain or disagreeable sensations is doubtful. It is 
true such children are frequently restless and sleepless, and a cotton pad as a 
support for the head appears to exert a soothing effect, but children who are 
models in sleep and in disposition are also affected with craniotabes. Cranio- 
tabes only occurs in those children who are kept mostly in the recumbent 
posture ; therefore constant pressure of these growing bones against the under- 
lying support is of causal import in this localization of rickets. Opposed to 
this is the occurrence of craniotabes in regions of the skull not exposed to 
pressure, as well as the fact that young dogs are also affected by craniotabes, 
notwithstanding the fact that in repose their head is supported upon their 
paws. 

Craniotabes is a common symptom of rickets and usually introduces the 
entire symptom-sequence of the affection. It nearly always appears during the 
first half, rarely during the third quarter, of the first year, and sometimes con- 
tinues after the second year ; but Monti remarks, quite rightly, that craniotabes 
in these later years dates from a period prior to the sixth month of life, and 
that rickets occurring after the sixth month does not give rise to craniotabes. 
The frequency of the softness of the occiput is indicated by the following com- 
pilation of M. Cohn from the poor population of Berlin : 

Of 100 children in the first three months of life 53.8 per cent, were affected 
with craniotabes; in the second three months 43.4 per cent., and in each of the 
last two quarters of the first year 38.35 per cent. These figures are certainly 
not too high. 

The second symptom of rickets of the cranium is a deficient involution of 
the frontal fontanelle and softness of the sutures. 



252 



RICKETS (RACHITIS) 



That the frontal fontanelle in a non-rachitic child gradually becomes 
smaller after birth * has been positively demonstrated after many controversies 
(Hochsinger, Kassowitz, M. Cohn). On the other hand, there is some doubt 
as to the time when a normal closure should occur. It is well to limit this 
period to the fifteenth or eighteenth month; not to the end of the first year 
as Kassowitz is inclined to do. This difference is important, as controversies 
may arise regarding the possible presence of rickets in children at the beginning 
of the second }^ear. Often, however, the frontal fontanelle in rachitic children 
is still open at the age of two and three years, but then other symptoms of 
rickets are usually noted. 

For comparison of the size of the frontal fontanelle in normal and rachitic 
infants, the following table of M. Conn's is instructive : 



Age 


Average Size of the Frontal Fontanelle 
in Cubic Centimeters 




Normal Children 


Rachitic Children 


1-3 months 


2.71 
2.62 
2.38 
2.25 
1.50 
0.67 
0.31 


4.04 


4-6 " 


4.44 


7-9 " 


5.0 


10-12 " 


4.88 


13-15 " 


3.54 


16-18 " 


2.95 


19-21 




22-24 " 


1.49 


2-2| years 


0.98 


2|-3 " 


0.55 







From this table it is evident that the frontal fontanelle of a rachitic child 
not only closes later but is larger than normal, and that in the first year of life 
it increases instead of decreases in size. 

In addition to enlargement of the frontal fontanelle in the rachitic skull 
the surrounding bone is not hard and sharply marginated, but is soft and 
yielding, so that in some cases the transition from the bone to the connective- 
tissue covering of the fontanelle is apparently gradual. This softness of the 
borders may also be recognized in the sutures of the skull, particularly the 
sagittal, the gaping of which in rachitic skulls frequently prevents an exact 
delimitation of the fontanelle. Kassowitz illustrates these fontanelles quite 
aptly by the figure co (without end). In such, skulls, with wide fontanelle and 



1 Many of our readers will not agree with the author when he says that " the frontal 
fontanelle in a non-rachitic child gradually becomes smaller after birth." He takes that 
to be " positively demonstrated," though he admits that a number of writers are of a 
different opinion. Constant observation of healthy babies will show that the large 
fontanelle grows up to the 7th or 8t!i month with, or rather in consequence of, the 
rapid lengthening of the lines of the adjoining bones. — Editor. 



SYMPTOMATOLOGY AND DIAGNOSIS 253 

gaping sutures, it is not always easy to distinguish between a simple rachitic 
and a hydrocephalic cranium. 

Anomalies in the size of the fontanelle and in the closure of the sutures, 
as the above table shows, appear, like craniotabes, at an early age, and are 
therefore a primary symptom of the affection. 

A third characteristic abnormality of the skull in rickets is the prominence 
of the frontal and parietal protuberances. This is due to bony deposits in 
these regions and gives to the forehead a very conspicuous convexity (" Olym- 
pic brow "). If the top of the cranium is depressed on account of the retarded 
ossification of the fontanelle, and the occiput flattened in consequence of 
craniotabes, the skull assumes a rectangular shape which is quite aptly desig- 
nated caput quadratum. The deposits of bone produce an increased circum- 
ference of the head which, however, does not indicate an increase in the 
capacity of the skull. 

The thickenings at the protuberances of the frontal and parietal bones, 
previously mentioned, do not correspond to the most florid stage of rickets but 
are the signs of beginning consolidation. They are therefore most marked at 
the end of the first year and later, and remain permanently as rachitic changes 
of the skeleton. In the half -grown child, and also in the adult, the " rachitic 
cranium " remains an important witness of the English disease, although in a 
moderately developed skull the boundary between rickets and family peculiarity 
is not always easy to determine. 

In severe rickets of the skull there are often disturbances in growth of the 
facial bones. The superior maxillary is elongated and narrowed, resulting in a 
higher palatine arch and a decided protrusion of the teeth. The lower jaw 
shows a characteristic change in that an angular projection at the point of con- 
tact of the anterior and lateral portions forces their approximation. This de- 
formity of the lower jaw is of practical interest for the reason that the space 
for the development of the teeth is limited and thus their eruption and growth 
are hindered. 

Of much greater and actually popular importance in rickets is the cutting 
of the milk teeth. The opinion, so often expressed, that rachitic children 
" teeth with difficulty " finds its support, on the one hand, in the nervous symp- 
toms which are sometimes present, and on the other in the late and irregular 
eruption of the milk teeth. When rickets begins early the first teeth, instead of 
erupting in the sixth or eighth month, do not appear until toward the end of 
the first or in the beginning of the second year. If rickets begins late the first 
incisor teeth may appear at the proper time, after which dentition is arrested 
and the remaining teeth are not erupted until far beyond the normal period. 
This delayed dentition is one of the most frequent accompanying symptoms of 
rickets. There are also marked cases of rickets with normal dentition of the 
milk teeth. Inversely, a delayed appearance of the deciduous teeth must not be 
regarded as an absolute sign of rickets, as it may be the expression of a family 
predisposition. 

Eickets affects not only the temporary but also the permanent teeth. The 



254 RICKETS (RACHITIS) 

abnormal formation of the jaws, mentioned above, forces the teeth together, 
causing deformity and a tendency to caries. The latter condition is further 
favored by the fact that the teeth of rachitic individuals, particularly the in- 
cisors, are often poorly developed and distorted by fissures, indentations, and 
erosions. This imperfection of the permanent teeth is due to the fact that the 
tooth pulp, during its development in the first years of life, is subject to the 
rachitic process like the osseous system. As the dentition of the incisor teeth 
and of the first molars occurs during the acme of rickets — in the first and 
second years — conspicuous changes are observed in these structures also. 
Therefore an incisor tooth, appearing in the sixth or seventh year and covered 
with erosions, is not a symptom of existing rickets but the result of a previous 
affection. The eroded incisors, which readily become carious, constitute one 
of the most conspicuous signs of rickets, although, as will be shown later, they 
cannot be employed in differential diagnosis in the absence of other phenomena. 
They represent permanent rachitic lesions which can be utilized beyond the 
age of infancy in the diagnosis of a former disease. 

In addition to the skull, the thorax frequently undergoes marked changes. 
At an early age, during the existence of craniotabes, thickening may be noted 
at the costochondral articulations. When the thorax is palpated these thicken- 
ings give the impression of a chain of beaded prominences and therefore have 
obtained the designation e( rachitic rosary." They are usually more marked 
in the lower ribs. They represent one of the most constant early symptoms of 
the disease, becoming distinct at the end of the first or beginning of the second 
year, or perhaps even in the congenital affection. 

Rickets gives rise also to other very conspicuous and serious changes in the 
thorax. In consequence of the softness and inelasticity of this structure the 
ribs undergo a change in shape which is manifest by a depression of the upper 
lateral portion of the thorax and by a sharp indentation at the point where the 
ribs and their cartilages unite. An alteration of contour results whereby the 
lateral walls of the thorax, instead of being arched, are flat or even concave. 
The upper thoracic wall is protruded and rises almost to an angle with the 
lateral portion. If, with this, there is a flattening of the posterior wall, in- 
stead of showing the normal ellipsoid the thorax may have almost a square 
appearance. This malformation affects only the upper portion of the thorax. 
The lower portion bends outward so that the deeper ribs appear inverted. A 
narrow upper portion and an extremely wide lower portion of the thorax 
results, between which a depression is noted, particularly upon forced respira- 
tion, which corresponds to the lower border of the lungs— Harrison's furrow 
(Stoltzner, Vierordt). 

This thoracic deformity may show various modifications or be altogether 
absent in rickets. At its extreme it presents that configuration known as 
"chicken breast" (pectus carinatum). Here the anterior portion of the ribs 
and the sternum are so prominent that the chest is wedge-shaped and its sterno- 
vertebral diameter in excess of the frontal diameter. Another not infrequent 
alteration of the thorax is produced when the costal cartilages at their insertion 



SYMPTOMATOLOGY AND DIAGNOSIS 255 

with the sternum are bent backward and sink groove-like below the level of the 
anterior thoracic wall. In addition to the softness of the ribs this deformity 
of the thorax owes its origin largely to the respiratory muscle-tug of the dia- 
phragm, the weakness of the other muscles of respiration, and the protruded 
abdomen (Vierordt). 

The changes of the thorax are the forerunners of later rickets and are 
most distinct about the middle or at the end of the second year. Notwith- 
standing their conspicuousness they often disappear in late childhood, so that 
in the adult there are only indications, seldom a well-developed type, of the 
rachitic thorax. These marked deformities have a deteriorating influence upon 
the ventilation of the lungs. Even with an intact respiratory apparatus they 
often give rise to dyspnea and diseases of the respiratory organs which lead 
to frequent and dangerous complications. It is evident that in such diseases 
forced respiration exerts a deleterious influence upon the shape of the chest, 
so that cause and effect in rachitic disease of the thorax may form an unfortu- 
nate combination. 

Children with rachitic thorax very frequently evince pain when they are 
raised by the axillae — a symptom which may be referred to the bones, but might 
also be due to the fear of increased dyspnea. 

Scarcely less common, but not associated with such serious consequences, 
is the effect of the rachitic process upon the vertebral column. This becomes 
unusually flexible, and when the children begin to sit up a very marked ley pilo- 
sis of the lower spine develops. This curvature of the spinal column is usually 
transitory and rarely leads to permanent malformation, although it may be the 
cause of much anxiety to the parents. It belongs to the early symptoms 
of rickets. Of greater importance is the dextro-convex dorsal scoliosis, such as 
appears in rachitic children between the ages of two and five years. This often 
persists and produces compensatory curvatures of other portions of the verte- 
bral column and permanent deformities of the chest. True scoliosis is not 
a very common symptom of the English disease. The curvatures of the spine 
which are observed in school-children and in adults are not always referable 
to early rickets ; as a rule they are acquired later. 

That in high-graded scoliosis displacements of the pelvic girdle must occur 
is in consonance with well-known suppositions. It is not these changes, how- 
ever, which play the fatal role in rickets, but alterations in the shape of the 
flexible pelvis which develop early from pressure and weight and lead to perma- 
nent narrowness. The flat and usually narrow rachitic pelvis is well known to 
the obstetrician and is one of the most serious consequences of the English 
disease on account of the great obstacle which it may raise in labor. In con- 
trast to most other rachitic anomalies of the skeleton, this change is of second- 
ary importance in the florid stage of the disease and is of little diagnostic 
value, but in women it constitutes a dreaded permanent sequel. 

The shoulder girdle and the upper extremities undergo various changes. 

The clavicle is frequently thick, with the normal curvature greatly exag- 
gerated. Not infrequently it is the site of infractions and fractures which are 



256 RICKETS (RACHITIS) 

often first recognized by decided callus formation. The distortions of the 
clavicle are usually combined with rickets oi the thorax and appear at the same 
age. They are sometimes a permanent sequel of rickets. 

Rachitis of the shoulder-blade produces a thickening and plumpness of the 
bones which may be recognized upon the spina scapulae but are of no diagnostic 
importance. 

In the upper extremities the enlargement of the epiphyses of the wrists 
must first be mentioned. Their circumference is often decidedly increased and 
they are distinctly separated from the carpal bones by a depression at the joint. 
From the two prominences which are thus formed upon the sides of this fur- 
row the popular designation " double joint " has been derived. These epiphy- 
seal protuberances appear with the first symptoms of the disease, sometimes 
appearing in the second six months, and add to craniotabes, wide fontanelles, 
and the rosary, one of the most valuable diagnostic criteria of rickets. 

Curvature of the humerus may be demonstrated anatomically as well as 
clinically, and infractions are by no means rare. 

The bones of the fore-arm often show a convexity upon the extensor side 
which is mostly referable to the muscle-tug of the flexors and pronators. Some- 
times there is an actual spiral curvature of these bones which results in a 
permanent pronation of the hand (Vierordt). In the lower arm also infrac- 
tions and curves may be noted. The curvature which appears in the lower 
third of the left fore-arm is attributed by Stone to the continual pressure at 
this point of the little finger of the person who leads the child. 

Finally, in the basal phalanges of the hand a thickening may be found 
(Fischl, Neurath) which resembles a carious process or an osteochondritis 
luetica. 

As these manifold changes, with their many combinations, lead in severe 
'cases to very conspicuous deformities, as well as to shortening of the arm,. 
they constitute an important diagnostic aid, although they cannot be employed 
much before the second or third year. Functional disturbances of movement 
may be associated with these changes whereby frequent flaccidity of the joints 
and decreased muscular activity, and possibly a painfulness of the bones, are 
subservient factors. These malformations of the humerus are relatively benign 
and tend to disappear, no matter how great their prominence in the acute stage 
of rickets. They are rarely seen in adults and when present are always asso- 
ciated with other gross changes of the skeleton. 

Of greater importance and subsequent effect are the rachitic changes in 
the lower extremities. These represent the final link of the chain of rachitic 
anomalies of the skeleton and first appear after walking and standing 
have exerted their deleterious effect upon the bones of the legs, although 
mild grades of the disease, such as curvature of the tibia, are said to exist 
prior to these, and, it has been asserted, can even be recognized in congenital 
rickets. 

The epiphyseal protuberances of the legs do not possess the same diagnostic 
value as those of the arms, although they are quite distinct in the ankles. 



SYMPTOMATOLOGY AND DIAGNOSIS 257 

Curvatures of the femur are not rare and are very conspicuous. A special 
form of the disease involves the neck of the femur, which joins the diaphysis 
less abruptly than normal, so that instead of an angle of 126° to 128°, it forms 
one of 100° or less. This causes adduction and outward rotation of the leg — 
the so-called coxa vara — and therefore interferes with the gait. 

The changes in the lower leg, especially in the region of the knee, are most 
important. Lateral or anterior convexities of the tibia and infractions are 
very common. According to the combination of these curvatures in both legs 
various postures result which Comby very aptly illustrates by the following 
signs: ( ), O-legs, genu varum (bow-legs) ; X, X-legs, genu valgum (knock- 
knees) ; D, unilateral, genu varum; K, unilateral, genu valgum. These by no 
means exhaust the possible positions of the legs. 

The result of the abnormal shape of the knee-joint is a peculiar position of 
the foot, which is aggravated by the flaccidity present in the joints of the legs. 

The origin of flat-foot may also be referred to rickets, but in half-grown 
individuals caution must be observed in attributing these static changes to a 
rachitic source. 

The changes in the legs, particularly the severer grades, are not a regular 
accompaniment of rickets and need be feared only in a small minority of early 
cases. When once developed they remain for some years, but even then there 
is a tendency to compensation ; therefore the advice of Veit, Kamps and others 
to desist from operative interference until the sixth year is well justified. 
Nevertheless, the number of cases is not small in which curvature of the legs 
is a permanent sequel and one of the most unfortunate consequences of the 
English disease. The bones of the leg like those of the arm are retarded in 
their longitudinal growth, and in severe rickets there is occasionally a shorten- 
ing of the entire osseous structure — rachitic dwarfism — such as has become 
familiar to us from the old pictures of " court dwarfs." 

A resume of the anomalies of the skeleton in acquired rickets, as regards 
their onset, frequency, and diagnostic importance, gives us the following: 

In the first six months craniotabes is the most reliable diagnostic sign of 
rickets. In the second half-year may be added the rosary, enlargement of the) 
frontal fontanelle, and epiphyseal protuberance at the wrist. Toward the end 
of the first or in the beginning of the second year the incomplete closure of the 
fontanelle, delayed dentition, and the arc-like kyphosis of the lower dorsal ver- 
tebra 3 , gain in diagnostic importance. In almost every case of early rickets these 
phenomena are combined. Not only do they belong to the most common symp- 
toms but they are also the most reliable factors in diagnosis. 

In further sequence, in the second and third years — but only in severe forms 
of the disease — deformities of the thorax and of the clavicle, curvatures of the 
vertebral column and of the extremities are added, the most conspicuous of 
which are those of the legs, with the previously-mentioned anomalous positions 
of the knee which usually appear latest, often at the end of the third year. At 
this age, in the majority of cases, though not invariably, craniotabes has disap- 
peared. The other primary changes, however, may continue, and the open 
18 



258 RICKETS (RACHITIS) 

fontanel les may persist after the disappearance of all the late symptoms of the 
affection. 

The disease may be arrested at any moment, between the development of 
craniotabes and that of curvature and shortening of the legs; therefore the 
number of rachitic cases with flattened occiput is considerably greater than the 
cases with curvature of the extremities. The severer grades of rickets usually 
occur in neglected children, that is, those in destitute circumstances; in the 
well-to-do a typical rachitis of the thorax and extremities is rare. 

Inversely, rickets which is not manifest until the end of the first year may 
lack the initial symptoms, especially craniotabes, and at once present the later 
changes. It is characteristic of such cases that the first milk teeth appear at 
the usual time but that long intervals elapse in the further processes of den- 
tition. 

This combination of late symptoms is most prominent in that form of 
the affection designated rachitis tarda, in which the osseous changes begin after 
the fifth year and sometimes not until the seventh or eighth year. These chil- 
dren complain of lassitude, cease to walk, and upon examination usually show 
conspicuous malformations of the skull, thorax and extremities. Such cases 
are not always of recently developed rickets but are the remains of an incom- 
plete recovery, that is, a revival of the affection which had existed in early 
childhood. 

Conspicuous and disfiguring as these osseous changes may be in the florid 
disease, nevertheless only a minority of them terminate in lasting alterations 
of the skeleton, in permanent sequels of rickets. We expressly refer to perma- 
nent sequels, not to permanent symptoms, because the osseous deformities in 
the adult do not possess the importance of residues of disease but are merely 
the product of cure, even though associated with alterations in the normal 
shape of the skeleton. The majority of the milder cases recover without 
sequels. A moderately severe affection sometimes leaves the broad head with 
prominent forehead and parietal bones, improper arrangement and composi- 
tion of the teeth, and also the narrowed pelvis — a scarcely obvious, although 
very important anomaly. Only in extreme cases do permanent convexities of 
the legs and deformities of the thorax and of the vertebral column occur, and 
especially rachitic dwarfism. 

The fact that rachitic children show no evidence of the affection in adult 
life must serve as a warning that too far-reaching conclusions must not be 
drawn from the absence of rachitic changes in the parents in behalf of the dis- 
ease in their children. 

With the changes in the skeleton the characteristic and most valuable 
diagnostic symptoms of the affection are exhausted. The clinical as well as 
the anatomical lesions — as we shall learn later — which are found in the viscera 
in rachitic subjects are neither peculiar to this disease nor are they always 
encountered. Therefore they may be regarded less as genuine factors than as 
accompanying symptoms of rickets, and only from the frequency with which 



SYMPTOMATOLOGY AND DIAGNOSIS 259 

the individual organic changes are found can we conclude that they are in 
intimate relation with this disease. 

The general nutrition is affected in various ways. With a rapid develop- 
ment of disease of the bone the increase in weight is retarded and the general 
condition is unfavorable, but, in the first year of life particularly, rachitic 
symptoms are observed in children that are fat and apparently robust. The 
pallor which is conspicuous in such infants is in contrast to the seemingly good 
condition of nutrition, and is seldom absent in well-developed cases. There is 
no clear explanation of this pallor. Blood examinations by Schiff, Widowitz, 
and others have revealed nothing characteristic of the disease, and the report 
of v. Jaksch that the salts in the blood are apparently decreased is thus far 
an isolated finding. 

Fever is never a symptom of rickets, and when present it is due to compli- 
cations. 

Chronic eczema of the head (impetigo, seborrhea) of marked grade is often 
associated with rickets. 

Whether enlargement of the spleen belongs to the symptom-picture of the 
English disease is the subject of discussion (Kuttner, Starck, Fox, Ball, M. 
Cohn, Miiller, etc.). The decision depends upon whether every palpable spleen 
is enlarged, and whether a splenic tumor is to be referred to rickets or to an 
accompanying affection. I agree with the majority of investigators that the 
occurrence of a palpably enlarged spleen in rickets is common though by no 
means constant, and believe we are justified in regarding it as an important 
accompanying symptom. 

Enlargement of the lymph glands is always the sign of some complication 
(Frohlich). This is also true of hyperplasia of the thymus gland (status thy- 
micus). 

The digestive tract usually shows conspicuous derangement in children 
suffering from rickets. First, the distended abdomen must be mentioned since 
it is usually regarded as the consequence of chronic digestive disturbances. 
This view, however, seems doubtful when the large abdomen is observed in the 
new-born or in children but a few weeks old, and when we consider that the 
characteristic frog-belly of the rachitic is generally absent in non-rachitic chil- 
dren even in chronic intestinal diseases. Therefore it is much more likely that 
this distention is due to a peculiar configuration of the abdomen, occurring 
only in the English disease, which may be the cause but not the consequence of 
disturbances of digestion. 

Great importance is attached to functional disturbances of intestinal diges- 
tion in rickets, which are regarded by some authors (notably Vierordt and 
Monti) as characteristic or etiologically important. Anorexia often alternates 
with bulimia; great discharge of gas is associated with colic; evacuation of 
dyspeptic feces of acid reaction alternates irregularly with constipation and 
the discharge of hard yellow stools. Bouchard and Comby believe that dilata- 
tion of the stomach is a regular accompaniment of rickets. No one will deny 
that all of these manifold disturbances of digestion — with the exception, per- 



260 RICKETS (RACHITIS) 

haps, of dilated stomach — occur in rachitis. In how far, however, they are 
peculiar to the disease, that is, are influenced by it, is difficult to decide, as, in 
the first place, investigations into the nature and frequency of intestinal dis- 
turbances in non-rachitic children have not been instituted; secondly, as 
Elsasser was aware, rickets may appear and continue without conspicuous dis- 
turbances of digestion; finally, an aggregate appearance of the disease after 
severe intestinal catarrh has by no means been observed. Nor must it be for- 
gotten that the theories of rickets which are based upon disturbed digestive 
chemism are not yet proven and that pathologic anatomy has not shown any 
important or characteristic intestinal lesion. Therefore intestinal disturbance 
in rickets has not the importance of a symptom but at most can only be 
ascribed to an accompanying condition wherein it is still uncertain whether 
rickets favors the appearance of digestive disturbances, that is, retards their 
cure. 

Enlargement of the liver is not rare in rickets but does not always accom- 
pany enlargement of the spleen. 

Much more serious are the accompanying symptoms and complications on 
the part of the lungs. As already mentioned, rickets of the thorax interferes 
with respiration, especially inspiration. This leads not only to dyspnea and to 
difficulty in cough but to insufficient ventilation of the lungs, to a ready devel- 
opment of catarrh, and to lobular pneumonia. These bronchial catarrhs are 
capable, through the forced respiratory activity, of increasing the deformity 
of the thorax and indeed of the entire skeleton. There is therefore a reciprocal 
action of rachitis of the thorax and diseases of the respiratory organs which 
certainly justifies the view that chronic catarrh and severe pneumonia are direct 
complications of rickets. 

Of diagnostic importance is the fact, mentioned by Eilliet and Barthez, 
that the alteration in the thorax and thickening of the shoulder-blades may, 
in percussion and ausculation, simulate diseases of the thoracic organs. Thus, 
over the supraspinous fossse occasionally there is absolute dulness; again, the 
cardiac dulness is sometimes apparently increased, or the respiratory mur- 
mur has, here and there, a pseudo-bronchial character. Stoltzner therefore 
quite properly suggests that in percussion of the rachitic thorax we should 
not enter upon " subtle refinements " but should rather depend upon 
auscultation. 

Nevertheless, the occurrence of cardiac hypertrophy, 1 especially of the right 
ventricle, in some rachitic children cannot be denied, but it must be regarded as 
a consequence of the increased resistance in the lesser circulation, due to pulmo- 
nary disease, rather than as a sequel of rickets. The over-exertion of the heart 
is probably the cause of the increased pulse frequency observed in rachitics, to 
which attention was called by Rilliet and Barthez and by Gruerin. Diseases of 
the respiratory organs, together with excessive cardiac activity, represent the 

1 The cardiac hypertrophy discussed by the author is often apparent only, and then 
due to the flattening of the (normally elliptic) chest which brings it into contact with 
a greater surface of the heart muscle. — Editor. 



SYMPTOMATOLOGY AND DIAGNOSIS 261 

gravest consequences of rickets and are frequently the cause of death in chil- 
dren suffering from that disease. 

The urine shows no special characteristics. Some authors mention a dis- 
agreeable ammoniacal odor from the diapers of rachitic children after thorough 
wetting. 

Attention has several times been called to muscular weakness 1 in rickets — 
an important although little understood symptom of the affection. Here we are 
dealing with a disturbance of function which is very conspicuous and to the 
parents is often the first indication of the disease. The children are backward 
in raising the head, sitting up, and in learning to walk. The last function in 
particular is mastered slowly and painfully and there is a preference either to 
sit with legs crossed like an oriental idol or to creep. Delay in the function of 
walking is so common in the well-marked disease that it may be regarded as 
a valuable sign of recovery from rickets. 

Also in rachitic children who have learned to walk there may be a sudden 
arrest of this function without an obvious increase of the symptoms. This has 
been designated by Comby pseudo-paraplegia, as the apparent paralysis of both 
legs does not correspond to a nervous lesion. Besides the effect of this muscu- 
lar weakness on the locomotion of these children it also plays an ominous role 
in respiration by lessening the action of the respiratory muscles, the stress fall- 
ing largely on the diaphragm. In pneumonic processes there is ready paresis 
of the muscles of respiration. Even the movements of the arms and hands 
in severe rickets may be affected by this muscular weakness. Much as we 
appear to be justified in regarding, like Vierordt, the muscular flaccidity as an 
essential symptom of rickets, but little change is to be found in the muscles 
by direct examination. During life there is merely a certain degree of emacia- 
tion and want of tonicity, without direct paralysis or even limited muscular 
atrophy. Anatomical investigation reveals general atrophy and insignificant 
changes in the muscles which are explained sufficiently by the disease which is 
the ultimate cause of death. 

Therefore the question must constantly arise whether the flaccidity of the 
muscles is a substantive factor of rachitis or whether it is a consequence of pain 
in the rachitic hones. But even if we agree upon a sensitiveness of the bones, 
our view is not well founded. It is true that children with rickets of the 
thorax often cry when their chest is touched, that frequently the first signs of 
rachitis are those of great unrest, and that attempts to walk are at first 

1 Muscular weakness is a very characteristic symptom when rachitis makes its ap- 
pearance early. It is observed both in the voluntary and involuntary muscles; and a 
cause of constipation in apparently normal, but rather fat, bloated babies about the 
third month. Part of the large size of the abdomen is the result of this incompetency 
of the intestinal muscle. The appearance of constipation at that time, while there was 
no change in feeding, is (almost) pathognomonic for rickets, in the same way that 
the congenital constipation of breast-fed babies is attributable to an undue length and 
flexures of the sigmoid part. The above "intestinal disturbance in rachitis has cer- 
tainly the importance of a symptom," and is not, as the author suggests, a merely 
" accompanying condition." — Editor. 



262 RICKETS (RACHITIS) 

resisted because of pain. On the other hand, older children do not complain 
of any disagreeable sensation in the bones and the anatomical examination of 
the skeleton, particularly of children who have evinced painfulness of the bones, 
is not different in its results from the examination of children in whom such 
conditions are absent. We may therefore consider a possible relation of muscu- 
lar flaccidity and sensitiveness of the bones, but cannot decide the question 
finally. 

A very interesting and much disputed chapter in the symptomatology of 
rickets is its relation to a number of nervous symptoms. 

It is obvious that an affection which is concerned with the rapidly matur- 
ing organism after affecting the skeleton may also attack the central nervous 
system, for the development of this part of the body is particularly active in 
the first years of life. Kassowitz has investigated the subject and upon the 
basis of rich clinical experience has described an entire series of nervous phe- 
nomena which result from, or, more properly, are the symptoms of rachitis. 
These in the order of their frequency are: (a) sleeplessness, sweating of the 
head, fright from impressions of sight and hearing; (b) facial phenomenon 
(Chvostek's sign); (c) inspiratory and expiratory spasm of the glottis; (d) 
general convulsions; (e) hyperidrosis universalis; (f) Trousseau's phenome- 
non; (g) spontaneous attacks of tetany; (h) spasmus nutans. 

It is quite impossible to relate in detail the many reports of the last decades 
concerning most of these nervous conditions of infancy, or even to indicate 
them. In the following we shall only consider the relation of these phenomena 
to rickets, and sketch briefly, in so far as that is possible, the views of the 
majority of authors regarding them. 

The nervous rachitic phenomena mentioned by Kassowitz may readily be 
reduced to a few pathologic types or symptom-groups. These are increased 
secretion of sweat and nervous unrest, spasm of the glottis, tetany, convulsions, 
and spasmus nutans. 

That sweating of the head and insomnia belong to the most frequent accom- 
panying symptoms of early rickets, that is, to craniotabes, certainly cannot be 
denied. As previously stated they are sometimes considered as prodromes of 
the affection. General sweating is a less frequent, but nevertheless common, 
complaint. That in these symptoms rickets represents a causal factor is very 
likely, whether rickets of the skull is responsible for sweating of the head and 
sleeplessness, or whether these symptoms are also an expression of a general 
rachitic dyscrasia, as is the case in craniotabes. 

Spasm of the glottis occurs during inspiration and expiration. In the 
former, after a few crowing inspirations, respiration is suddenly arrested and 
the respiratory organs remain fixed in that position. Inversely, in expiratory 
apnea (Kassowitz) the larynx and thorax are fixed in expiration. These phe- 
nomena occur in crying but may also be spontaneous. They usually last a 
fractional part of a minute and are associated with fright. In severe attacks, 
particularly when there is expiratory dyspnea, there may be cyanosis, loss of 
consciousness, and convulsions. Even in these cases recovery is frequent; 



SYMPTOMATOLOGY AND DIAGNOSIS 263 

nevertheless the number of children who succumb to this spasm of the glottis 
is not small. Therefore, laryngospasm must be reckoned among the most 
dangerous diseases of infancy. 

Children who suffer from spasm of the glottis are mostly rachitic. Whether 
or not laryngospasm is always due to rickets was the subject of an active con- 
troversy between Loos and Escherich on one side and Kassowitz on the other, 
which was ventilated at various congresses and in several publications, and on 
either side has gained many adherents among pediatrists. 

In support of his view of the undoubted relation of rickets and laryngo- 
spasm Kassowitz has mentioned a number of facts : In the first place spasm of 
the glottis is found only in children with rachitic phenomena; further, the 
most frequent occurrence of both conditions is in the spring months; again, 
the prompt action of phosphorus in spasm of the glottis is a proof of its 
rachitic foundation. He has also given an anatomical explanation for the 
development of laryngospasm in his assumption that through the hyperemia of 
the rachitic bones of the skull certain cortical centers are irritated which give 
rise in the animal experiment to inspiratory and expiratory positions of the 
larynx. 

In the critical analysis of these arguments laryngospasm and tetany can- 
not be separated. Although it must be admitted that in the individual case 
spasm of the glottis may occur without other symptoms of tetany, nevertheless 
their frequent combination together with the electric hyperirritability of the 
nervous system which occurs alike in both diseases (Thiemich) shows that as 
a matter of fact there is no distinction between laryngospasm and tetany. We 
cannot enter into all the details of this greatly discussed question of tetany, 
but in so far as its relation to rickets is concerned it is certain that similar con- 
ditions are operative for spasm of the glottis and for tetany. 

Much may be said against a strict connection between rachitis on the one 
hand and laryngospasm and tetany on the other. 

Both conditions are also observed in non-rachitic children, but then the 
opinion that an open fontanelle at fifteen months is a sign of rickets cannot 
be upheld. There is no congruity between the severe forms of rickets, espe- 
cially craniotabes and laryngospasm, and tetany. On the contrary, nervous 
symptoms are sometimes absent in extreme cases of rickets and again may be 
present in the mildest forms of the affection. The coincidence of spasm of 
the glottis and tetany with an increased rachitic frequency in the early months 
of the year has its analogon in the appearance of tetany in adults during the 
same season. Besides, there are characteristic curves at different seasons for 
other nervous affections. Tetany and with it spasm of the glottis occur in 
certain years and in special regions in the form of epidemics, while in other 
countries (France) they are very rare. Eickets, on the contrary, is of about uni- 
form frequency and is widely distributed even in regions free from tetany. At 
the time of onset of tetany or of laryngospasm the rachitic symptoms undergo 
no change and the process continues after the nervous phenomena have dis- 
appeared as though they had never existed. A change in the food may be fol- 



264 RICKETS (RACHITIS) 

lowed by a sudden disappearance of the spasm of the glottis or of tetany, 
where a rapid change in the rachitic disposition cannot be assumed. The rela- 
tion of definite cortical centers to spasm of the glottis is very unlikely, for iso- 
lated spasm of the laryngeal muscles is never observed in other cerebral affec- 
tions (tumor, meningitis, encephalitis), as would be inevitable if a cortical 
center were involved. Nor is it manifest why, of all the known centers upon 
the surface of the brain, only two, which are otherwise inactive, can be stimu- 
lated by hyperemia of the rachitic cranial vault, while isolated spasms of the 
extremities, of the ocular muscles, or of the facial nerve are absent in rachitis. 
In addition to this is the fact that particularly the laryngeal centers in question 
correspond to the frontal brain, which is therefore but little affected by the 
rachitic process, while functional anomalies in other centers, for instance in the 
occipital lobe, may be absent notwithstanding high-graded craniotabes. 

Finally, the fact must be considered that tetany, with its constant bilateral 
spasms, with its increased nervous and muscular excitability, with its undis- 
turbed sensorium, and with its absence of all cerebral symptoms, by no means 
corresponds to our conception of a cerebral clinical picture but probably has 
its seat in spinal centers or in the peripheral nervous system. 

Therefore, the only remaining indication of the rachitic origin of laryngo- 
spasm and of tetany is the prompt success of treatment with phosphorus. But 
by no means does this appear to be reliable evidence, for it does not stand to 
reason that the result of phosphorus treatment, which is often noted within 
tw^o or three days, should affect the osseous structure alone, in which weeks 
are required for the distinct appearance of changes. It is more probable that 
the phosphorus acts upon the nervous system the same as upon the bones, so 
that no conclusions in favor of a relationship of rickets and laryngospasm can 
be drawn from the therapeutic reaction. 

The answer to these questions must be that we are not justified to include 
spasm of the glottis and tetany among the symptoms of rickets, and, although 
clinically there is a frequent coincidence of both conditions, the theoretic con- 
clusions of Kassowitz must be rejected. Escherich, the former opponent of 
Kassowitz, has attempted to overcome this by advocating a subdivision of 
tetany under the term " tetany of rickets," to indicate that it mostly affects 
children suffering from the English disease but is not its consequence. But 
this cannot be regarded as a very happy expedient, for no decision is reached, 
and Escherich must also include in this group those cases of infantile tetany 
in which a typical tetany attacks a non-rachitic child. 

This by no means decides the question of the relation between rickets and 
laryngospasm or tetany. New points of view are probably necessary to re- 
awaken an interest in the condition in the scientific world. A paper which 
Pineles recently read in the " Wiener Gesellschaft der Aerzte " seems to open 
a new perspective. According to this investigator tetany may be referred to a 
damage of the epithelial bodies in the vicinity of the thyroid gland. If we 
consider that Stoltzner refers rickets to a disturbance of an organ yet un- 
known with "an internal secretion," there is in this parallelism a possible 



SYMPTOMATOLOGY AND DIAGNOSIS 265 

starting-point for investigations which may throw light upon the subject of 
rickets and its relation to -tetany. 

Similar to the problem of tetany in rickets is also that of convulsions. The 
frequency of general convulsions in rickety children must be admitted, but 
there is no absolute evidence that rickets exerts more than a predisposing influ- 
ence on the readily active cause of convulsions. Therefore children with high 
fever and with intestinal intoxication are more prone to convulsions if they 
are rachitic, but thus far there is no reason to regard rickets, as such, as a 
causal factor. In these cases treatment with phosphorus by no means shows 
such brilliant results as in spasm of the glottis. 

Among the nervous symptoms as yet unmentioned, the slightest relation 
to rickets is probably found in spasmus nutans and nystagmus. These con- 
stantly combined conditions also probably occur most frequently in the early 
months of the year, but are by no means dependent on the presence of rickets, 
and sometimes befall strong children who begin to walk early. Their duration 
is a few weeks, sometimes months. Whether treatment with phosphorus de- 
cidedly shortens the affection is difficult to prove. 

Among the other nervous symptoms ascribed to rickets the following must 
be mentioned : 

The facial phenomenon (Chvostek's sign), which is also encountered with- 
out tetany in rachitic children, has nothing in common with rickets, as it 
occurs in older children also in the spring months, and is not unusual in adults. 

Disturbances of the sense of taste, which Lichtenstein claims to have noted 
in a great number of rachitics, frequently have not been found in subsequent 
examinations and cannot always be regarded as signs of simple rachitis (Biis- 
sem, H. Neumann). 

Peculiar cataleptic conditions, in which older rachitic children remain for 
some time in unusual passive positions, have been described by Epstein and 
Thiemich. The symptom is not common and its relation to rickets has not 
been proven. 

That there cannot be an absolutely characteristic mental and intellectual 
disposition of rachitics is evident from the fact that nearly 80 per cent, of 
the population of a large city were rachitic in their youth. In how far rest- 
lessness and the tendency to scream of many rachitics can be referred to a 
predisposition to disease, to stress of respiration, to sensitiveness of the bones, 
is difficult to decide. It is certain that in addition to these " bad " rachitic 
children we find others who are particularly friendly, gentle, and amiable. 

Nevertheless, it is an undeniable fact that many rickety children develop 
slowly, and especially are backward in learning to talk, which, together with 
tardiness in locomotion, give the impression of backwardness. 

It is likely that this mental tardiness does not belong to rickets, as such, 
but represents one of the most curious complications of the affection, namely, 
hydrocephalus. As to the frequency of rachitic hydrocephalus there are great 
differences of opinion (for example, Henoch and v. Eitter). There can be no 
doubt, however, from the clinical and anatomical findings that hydrocephalus 



266 RICKETS (RACHITIS) 

occurs not rarely in connection with rickets. It is true, the clinical picture of 
hydrocephalus is not very marked. Unusually great circumference of the 
head, open fontanelles and sutures leave a doubt in the individual case as to 
what part of the condition is due to rickets and what part to hydrocephalus. 
In rachitic hydrocephalus the symptoms of brain pressure and paralysis are 
absent, as well as a progressive or a regressive course which otherwise is pecu- 
liar to hydrocephalus. If in rickets the well-known hydrocephalic symptoms 
occur which relate to the position of the eyes, spasm, convulsions, etc., we are 
probably justified to search for other causes of hydrocephalus and no longer 
to regard them as purely rachitic. The only symptoms which characterize the 
hydrocephalus of rickets are headache, a certain degree of mental sluggishness, 
and retarded development of speech. It is possible that rachitic hydrocephalus 
predisposes to later epilepsy, although the importance of the " rachitico-hydro- 
cephalic skull " mentioned so frequently in the history of patients with nerv- 
ous disease must not be exaggerated. 1 

Of as little prominence as the clinical symptoms of rachitic hydrocephalus 
is its anatomical picture, in that we usually find nothing more than a moderate 
dilatation of the cerebral ventricles without obvious signs of a past inflamma- 
tion. In fact this finding is not rare in rickets and must probably be regarded 
as symptomatic of the affection. How this accumulation of fluid in the cere- 
bral ventricles arises has not been positively proven. Stoltzner has offered the 
following hypothesis: The periosteal proliferations of the cranium produce 
a narrowing of the communication between its internal and external spaces and 
cause a stasis of lymph in the interior of the skull which is manifested by dila- 
tation of the cerebral ventricles. Stoltzner regards this theory as purely specu- 
lative, but it deserves consideration, since not an actual " rachitic disease " of 
the brain is assumed, but an occasional occurrence of rachitic hydrocephalus 
from disease of the bones. 

A condition altogether obscure is the occasional finding in the autopsy of 
rachitics of hypertrophy of the brain, which is evident not only by the con- 
spicuous size, but also by a special firmness of the organ. Clinically this con- 
dition gives rise to no distinct symptoms 2 and is scarcely to be identified as 
actual hypertrophy of the brain with symptoms of cerebral pressure which 
causes death (Schick). 

This exhausts the most important points in the symptomatology of rickets. 

In what relation are these individual signs of disease with the rachitic pro- 
cess? Which of them are conspicuous symptoms of the affection, which are 

1 In connection with hypertrophy it must strike us that previous to a final hydro- 
cephalus there is oedema. These brains are always cedematous, and their functions 
influenced by the amount and locations of the parenchymatous oedema. — Editor. 

2 Hypertrophy of the brain does " give rise to distinct symptoms," if a large size 
of the head, with normally developed cranial bones and symptoms of pressure, with 
tendency to occasional convulsions belong to the class of - distinct symptoms. The 
cases are rare, but discussed as early as 1857 in the New York Journal of Medicine 
("On the premature ossification of the cranial sutures and fontanelles"). — Editor. 



SYMPTOMATOLOGY AND DIAGNOSIS 267 

the direct consequences, and which are frequent but not absolutely certain 
accompanying conditions'? 

Only the changes in the skeleton can be regarded as positive symptoms of 
the English disease. These, in their individuality and grouping, are found in 
no other disease and represent absolutely positive diagnostic criteria. Further 
signs of the rachitic dyscrasia are the peculiar pallor and softness of the skin, 
the flaccidity of the muscles, the enlarged spleen, and the nervous unrest. 
Whether the digestive disturbances are expressions of the rachitic disease or 
accompanying phenomena cannot be positively determined. 

The primary direct consequences of the rachitic osseous process are diseases 
of the respiratory organs, and next in order those of the circulatory system. 
Here hydrocephalus as well as the questionable painfulness of the bones must 
be included, which, in combination with the muscular flaccidity, may cause 
delay in the locomotor functions. 

A frequent accompanying condition, but by no means due to rickets, is 
found in the other nervous complications. Perhaps their coexistence is to be 
explained, as some authors assume, by the presence of etiologic factors com- 
mon to both diseases. 

We must now briefly discuss the relation of rickets to certain other affec- 
tions. 

After the rejection of Parrot's view, that every case of rickets is due to 
hereditary syphilis, the relationship of the two diseases is limited to the fact 
that children who are hereditarily syphilitic are especially subject to rickets. 
Recently Hochsinger has thoroughly investigated this question and has sought 
to prove it by figures, but his statistics show conspicuously that the rickets of 
syphilitics is of a particularly benign nature and is rapidly cured. If to this 
we add the reports of authors who have not noted a frequent occurrence of 
rickets in children with inherited syphilis (Stoltzner), the intimate relation 
of the two conditions becomes very insignificant and perhaps may resolve itself 
into the fact that debilitated children acquire rickets more readily than those 
who are healthy. 

The theory of a causal connection of rickets with malaria, which Oppen- 
heimer attempted to prove, has been entirely rejected. 

The relation of rickets to B arlow-M oiler s disease (infantile scurvy) is still 
the subject of discussion. The affection has been directly designated as acute 
or hemorrhagic rachitis. Their affiliation is limited to the common occurrence 
of Barlow's disease in rickety children — a circumstance which, as there are 
exceptions to it (Rehn), probably only represents the statistical sequence of 
the frequency of rickets. Artificial nutrition may possibly be a connecting 
link between rickets and infantile scurvy. 

That rachitic individuals readily incline to tuberculosis has been known 
since the investigations of v. Eitter. Nevertheless, we must not consider their 
combination in the sense of a direct relation between the rachitic and tuber- 
culous predispositions of the entire organism, but must regard the debilitated 



268 RICKETS (RACHITIS) 

constitution of rachitic children, the great tendency to diseases of the respira- 
tory organs, and the common disturbance of the digestive faculty as the fun- 
damental conditions for the successful entrance of tubercle bacilli. 

It cannot be denied that in severe rickets, particularly when associated with 
hydrocephalus, there is a tendency to epilepsy, or, more correctly, that among 
adult epileptics there are conspicuously many with rachitic skulls. Here also 
there is an apparent necessity for a connecting link between rickets and the 
nervous affection, in which sense perhaps we may consider rachitic hydro- 
cephalus. As we have found this affection to be in intimate relation to rickets 
we must necessarily designate epilepsy as a malady to which cases of recovered 
rickets show a predisposition. 

VII. DIFFERENTIAL DIAGNOSIS 

The differential diagnosis of rickets presents no confusion if we adhere 
strictly to the changes in the bones, which, in their characteristic form and 
intimate connection, are not duplicated in any other disease. Affections of 
infancy which run their course with changes in the skeleton are most readily 
confused with rickets. Primarily among these is infantile myxedema, which 
often resembles the English disease in the enlargement of the epiphyses and 
the cartilage of the ribs, the delayed closure of the fontanelles, and the appear- 
ance of the teeth ; but the peculiar physiognomy, the macroglossia, the nature 
of the subcutaneous cellular tissue and the hair, and the absence of sweating 
are unmistakable signs of the myxedematous disease, and even the bony 
changes, notwithstanding their similarity, have no affinity with those of 
rachitis. 

Hereditary syphilis may in some instances be confounded with rickets. 
This would happen if a luetic osteochondritis at the joint ends were to resem- 
ble the rachitic enlargement, if luetic and rachitic hydrocephalus must be dif- 
ferentiated, if syphilitic softening of the bones or deposits upon the skull were 
present, if the distinction between rachitic and late luetic curvature of the 
tibia must be made, and if, finally, conclusions as to the presence of syphilis or 
rickets must be drawn from the changes in the teeth. 

From these osseous symptoms of hereditary syphilis osteochondritis can, 
as a rule, be determined without difficulty by its usually unsymmetrical locali- 
zation, by the pain, by the commonly accompanying paralysis (pseudo-pa- 
ralpsis luetica), and by the prompt relief after antisyphilitic treatment. 
Syphilitic bony deposits on the skull and craniotabetic softenings (Stoltzner) 
may cause great perplexity and can only be distinguished from rickets through 
the different localization of thickening, and by their sharper limitation and 
higher protuberance. On the other hand it scarcely seems possible positively 
to recognize a rachitic-luetic hydrocephalus in its late stages by the form of 
the skull, as the cranium natiforme, which was formerly supposed to belong 
only to syphilis, may occur also in rickets. In this case the differential diag- 
nosis will often depend upon the clinical hydrocephalic symptoms, which 



DIFFERENTIAL DIAGNOSIS 269 

appear earlier in syphilis than in rickets. The curvatures of the tibia of 
syphilis tarda have the shape of a curved scabbard, in that they are flattened 
and are convex anteriorly, while in rickets the curvature is in the frontal plane. 
A rule, it must be admitted, with many exceptions! In the teeth we must 
remember that only the semilunar curvature of the two central upper incisors 
(Hutchinson's teeth) warrants a suspicion of syphilis; all other erosions and 
indentations may occur in other affections of infancy and particularly in 
rickets. 

Barlow's disease may in its casual aspect be confounded with rickets and 
is often mistaken for it (acute rickets). The similarity exists in the painf ill- 
ness of the bones as well as in the protuberances, though the former is more 
acute than in rickets and is mostly limited to the legs, and the latter is more 
marked in the diaphyses, which are much more frequently the seat of periosteal 
hemorrhage than the epiphyses. If, in addition, there is extravasation of blood 
in the mouth and the mucous membranes the diagnosis of morbus Barlowii 
can scarcely be doubted. 

The permanent changes in the rachitic skeleton are differentiated from 
osteomalacia less by the osseous softening than by the development of the latter 
affection in the adult and the occurrence of the softening at a period when the 
rachitic changes would have become prominent and fixed. The occurrence of 
true osteomalacia in older children, in spite of reports to the contrary ( Siegert. 
Eoon), has not yet been determined with such certainty as to be of practical 
importance in a differentio-diagnostic respect. The difference between osteo- 
malacia and rickets is found particularly in the anatomical relations and at 
this time is merely of theoretic interest. Stoltzner emphatically declares that 
the erection of these sharp anatomical divisions is unjustified. 

Among the rachitic symptoms kyphosis may be confused with spondylitis, 
rachitic pseudo-paraplegia with poliomyelitis, the distended abdomen with 
meteorism, i. e., tuberculous peritonitis, coxa vara with congenital luxation of 
the hip- joint, and great difficulty may arise if the condition is not correctly 
understood. 

Radioscopy, which has been so successful in the last few years, promises 
valuable results in the diagnosis of rickets. The reports which have thus far 
been published relate particularly to the rachitic child. While in a normal 
tubular bone, for example, on the distal ends of the radius and ulna or on the 
middle bones of the hand, the epiphyseal joint is sharply marginated, as though 
lined with a ruler, and shows a decided linear shadow, in the rachitic bone 
the epiphyseal border is but slightly prominent, not in a straight line but as 
if beaker-shaped and fibrillated. Differences may also be recognized in the 
structure of the diaphysis, in that the parallel striations and regular contour 
of the normal bone make way for an irregular deposit of osseous trabecular, 
and lighter areas are noted in parts that are but slightly calcified. 

Differentio-diagnostic X-ray examinations in luetic osteochondritis (Hoch- 
singer), myxedema, and mongolism have already been instituted, but thus far 
they lack systematic comparison. 



270 RICKETS (RACHITIS) 



VIII. PROGNOSIS 

If we adhere strictly to the changes in the skeleton it must be admitted that 
rickets unquestionably terminates in recovery. In fact, we may doubt whether 
ire (ire dealing with a disease in the ordinary sense but rather with a disturbance 
in development. The bony changes which we recognize as the expression of 
" florid " rickets disappear in every case and the affection is never found in 
adults. Our attention, therefore, is not directed to a cure, as such, but to the 
prevention of too great a distribution of osseous changes and of deformity 
in the healed bones. The physician's object in this is similar to that in frac- 
tures, which, as is well known, may unite without treatment, but nevertheless 
require management to prevent a subsequent disturbance in function. 

In this broader sense the prognosis of rachitis is uncertain and not always 
favorable, as even treatment will not positively insure an arrest of the rachitic 
process, and in severe cases we are helpless against a recovery with permanent 
anomalies (for example, changes in the pelvis, kyphoscoliosis). 

If, in addition, we include those conditions which, although not directly 
belonging to the affection, are intimately associated with it, the prognosis be- 
comes even less favorable and our treatment more inadequate. Thus the prog- 
nosis of the pulmonary affection in rachitic children especially is very much 
more serious than in healthy ones; the prognosis in laryngospasm, in tetany, 
and in convulsions, notwithstanding the favorable effect of phosphorus, is 
doubtful, and the cure of intestinal catarrh is mostly very protracted. 

In pulmonary inflammation and spasm of the glottis lie the main dangers 
of the rachitic. These complications represent causes of death which are to be 
regarded as the direct consequences of the English disease. 

Therefore, when there is any implication of the respiratory organs, or any 
other affection of infancy, rickets in general is a prognostically unfavorable 
factor, and the course of influenza, measles, whooping-cough, diphtheria, etc., 
in rachitic children is liable to be more severe than in children previously 
healthy. 

But even " cured " rickets may have serious consequences for the person 
affected. Thus, a kyphoscoliosis upon the activity of the heart and lungs, a 
narrowed pelvis upon the course of labor, hydrocephalus upon mental develop- 
ment, general curvature of the bones and dwarfism upon social position and 
capability for various occupations. If we continue this conception, the emphy- 
sematous hump-back perishes, hemorrhage follows rupture of the uterus in 
consequence of narrowed pelvis, individuals suffering from rachitic deformi- 
ties grow tired of life, and with decided narrowing of the pelvis death of the 
second generation may occur intra partum, or the health may be permanently 
destroyed (hemorrhage of the brain, paralysis). 

From this it is sufficiently evident that rickets, no matter how we regard the 
nosological position of the florid osseous changes, is a condition of serious 
import, and that professional activity, even though limited to the prevention of 



PATHOLOGIC ANATOMY 271 

too great a distribution and dangerous complications, has before it a wide and 
beneficent realm. 

IX. PATHOLOGIC ANATOMY 

In the description of the pathologic anatomy of rachitis we are concerned 
almost exclusively with the characteristic changes of the skeleton. In this 
chapter we shall depend largely on the reports of Virchow, Kassowitz, Pom- 
mer, and Stoltzner, who have materially broadened our knowledge of the con- 
dition. 

According to Pommer the rachitic disease of the skeleton is distributed 
over the entire osseous system and becomes especially manifest in those areas 
of most active growth of bone. From the anatomical standpoint the course 
of the affection may be divided into a stage of onset, of acme, and of cure, 
the transitions of which necessarily are not sharply denned. First, however, 
it would be well, for an understanding of the anatomical foundation of the 
affection, to describe the changes which take place at the acme of the disease. 

The following must be emphasized as characteristic factors of the rachitic 
bony process: hyperemia of the hones; irregular formation and proliferation 
of the tissues in which normally osseous formation occurs; deficient secretion 
of. calcium in these tissues, and the pathologic decalcification of hones that 
already contain calcium. 

The normal production of bone occurs in the periosteum and at the osteo- 
chondral horders, and here the essential anatomical factors of rachitis are 
established. 

The periosteum is for the most part decidedly thickened. It is closely 
adherent to the bone and can be loosened only with difficulty. The thicken- 
ing is due to a hyperemic layer between the fibrous periosteal cover and the 
bone, consisting of alternate porous, plexus-like tissue and coarse longitudinal 
bands. Microscopic investigation reveals a substratum, rich in cells, which is 
interrupted by medullary vascular spaces. This " osteoid " tissue resembles 
the bony tissue, but differs from it in its reaction to stains as well as by the 
absence of the ordinary deposits of lime. It is true, upon the external layers 
of this proliferated periosteal cover there are disseminated deposits of calcium 
salts which gradually become richer as they invade the bone ; but even in those 
areas in which ossification occurs the osseous trabeculge are surrounded by 
osteoid tissue. There is, therefore, a thickening of the periosteal layer with 
the formation of osteoid tissue, numerous blood-vessels, and a retarded ossi- 
fication. 

Even more conspicuous are the changes at the osteochondral horders of the 
tubular bones. 

Section of a normally growing hone reveals between the osseous and carti- 
laginous structures a limited and sharply-defined bluish zone of calcification 
several millimeters in thickness. Histologically the bone formation appears 
about as follows: Cutting centerward from the cartilaginous epiphysis we 



272 RICKETS (RACHITIS) 

find that the cartilage cells, which were at first deposited irregularly, arrange 
themselves in definite rows corresponding to the direction of growth, and begin 
to enlarge. The intermediary substance of these cell columns takes up lime 
salts and then becomes the zone of provisional calcification. From points of 
vascular ossification in these layers of cartilaginous proliferation capillaries 
originate which cause resorption of the cartilaginous tissue and form medul- 
lary spaces, in the walls of which, by proliferation of cells introduced through 
the vessels (osteoblasts), true bony tissue forms and soon becomes a compact 
structure by deposition of calcium salts. 

In well-developed rachitic bones these conditions are essentially changed. 
The osteochondral boundary is markedly widened — to 1 cm. in thickness — and 
conspicuously red. In contrast to the normal cartilage the end is not sharp 
but serrated. As in the normal bone, the cartilaginous cells are first arranged 
in rows and afterwards clump together, forming larger nests. The enlarge- 
ment of the cartilage cells, however, is much greater. The lines of direction 
are less conspicuous the closer we approach to the diaphysis. The proliferating 
capillary branches permeate this " chondroid " tissue much more deeply than 
in the normal bone, so that in place of a uniform approximation of the carti- 
lage columns and medullary spaces there is a quite irregular interlacing of 
these histologic elements. Of essential importance in rickets is the fact that 
through the action of osteoblasts a structure arises which resembles bony tissue ; 
this osteoid tissue, however, as was seen in the periosteum, differs micro-chemi- 
cally from true decalcified bony tissue and shows but slight tendency to cal- 
cification. 

Therefore, in the enchondral ossification, just as in the periosteal, there is 
an enlargement of the zone of transformation, a marked hyperemia of the same, 
as well as the formation of osteoid tissue and delayed calcification. The last 
factor is of essential importance in rickets. There is a conspicuous dispro- 
portion between the broad transitional zone, which is ready for ossification, and 
the slight deposit of calcium which is found there. The consequence of this 
is an abnormal softness at the epiphysis and a ready separation of the epiphysis 
from the diaphysis in the macerated bone. 

A further rachitic stigma is the decalcification of bones already compact. 
It is questionable whether this is an actual occurrence. Virchow has pointed 
out as an undoubted differential factor between rickets and osteomalacia that 
in the latter affection solid bone is absorbed, while in rickets the soft bony 
tissue does not become compact. This view was opposed by v. Becklinghausen 
and more or less by Pommer, Cohnheim, and Stoltzner. Heubner limits the 
resorption of bone to the severest " osteomalacic " forms of rickets. 

Stoltzner has called attention to a change with loss of calcium of the bone, 
an osteoporosis. " A portion of the Haversian canal is often dilated, forming 
larger medullary spaces ; " in many cases half or even more of the entire 
skeleton " is replaced by a loose, fibrous, medullary tissue." Such an osteo- 
porosis, which is found especially in the external portions of the corticalis, 
according to Schwalbe is normally present in children from the sixth month 



PATHOLOGIC ANATOMY 273 

to the end of the second year. It is Stoltzner's opinion, however, that it is more 
marked in rickets and is due to the fact that the apposition of the bone is far 
behind its absorption. An interesting result of Stoltzner's experiments in 
feeding animals with food poor in calcium was the occurrence of an osteo- 
porosis of this sort without a rachitic change of the bone. This author also 
assumes that by treatment with phosphorus only the osteoporosis is influenced, 
the bones becoming firmer, but that the actual rachitic change — the deficient 
calcification of the osteoid tissue — is uninfluenced. 

A review of the consequences which necessarily arise from these histologic 
changes in the shape of the rachitic hones gives the following: The bones are 
markedly hyperemic, alike in the periosteum, in the zones of ossification, and in 
the marrow. Through the great proliferation and the deficient calcification 
of the periosteum, as well as from the absorption of bone, they are abnormally 
soft. It is not difficult to cut or even to sever them, nor to change their shape 
by external force. This gives rise to the many deformities and curvatures of 
the skeleton with which we have become familiar from the symptomatology. 
In addition there are infractions and fractures which affect the shape of the 
bones of the extremities and the clavicle. A further consequence which has 
been mentioned is the softness and protuberance of the osteochondral borders 
of the long bones. Finally, there is an irregular periosteal deposit and by 
softening processes in the flat bones of the skull an irregular thickening and 
thinning is produced, the borders of the bone being thickened, the thinness 
affecting principally the squama of the occipital bone and the dependent por- 
tions of the parietal bones, in which probably unfavorable conditions are 
brought about by opposing pressure of the brain and of the underlying surface. 

In this series of tony changes all of those anomalies of the skeleton may he 
included which are met with in rickets: Craniotabes, double joints, the rosary, 
narrowed pelvis, and finally, the curvatures and deformities of the thorax and 
extremities. 

How are these anatomical findings to he explained? Two diametrically 
opposed views have been given: Kassowitz's law of a chronic inflammation 
and Pommer-Heubner ? s view of a primary deficient calcification. 

Kassowitz regards proliferation and dilatation of the vessels as the essen- 
tial characteristics of rickets. Deposition of calcium salts predisposes to slug- 
gishness of the circulation remote from the centers of great blood supply. As 
there is an unusually profuse formation of blood-vessels, and therefore an 
active circulation at the points of ossification, the deposit of calcium salts 
is interrupted and the cartilage remains soft. An analogy for this deficient 
lime formation, due to over-active circulation of the blood, is found in large 
tumors and other tissues in which formation of calcium and even bone forma- 
tion takes place in areas of deficient circulation. 

To this theory of inflammation, which undoubtedly is an ingenious inter- 
pretation of actual findings, Pommer and Heubner are decidedly opposed. 
They did not find the histologic signs of inflammation, especially the small- 
cell infiltration, and regard the vascular proliferation as a secondarv svmptom. 
19 



274 RICKETS (RACHITIS) 

On the contrary, that primary and essential in the rachitic process is the for- 
mation of an osteoid tissue which possesses no tendency to prompt ossification. 

In connection with this Heubner attempts to construe a histologic picture 
of the zone of calcification that would arise if a rapid change of osteoid into 
bony tissue were to occur at the osteochondral boundary. Through the absence 
of the firm hold which is normally presented by the deposits of layers of cal- 
cium salts, the columns of cartilage cells as well as the newer capillaries lose 
their alignment and the ordinary growth of both tissues side by side is dis- 
turbed. Therefore the transition into bony tissue of the cartilaginous cells 
which have reached a certain degree of maturity fails to occur and the cell 
columns continue their growth and become unusually broad and long. On 
the other hand, on the diaphyseal side vessels have arisen, have formed medul- 
lary spaces, and have come in contact with the cartilaginous cell columns with- 
out the occurrence of uniform fusion. This theoretically constructed histo- 
logic picture actually corresponds with the findings in rickets. Heubner is 
therefore inclined to regard the deficient transformation of the osteoid tissue 
into bony tissue as the only determining factor, and does not recognize the 
" proliferation " of the cartilage, as such, but sees in this distribution of the 
cartilaginous zone a secondary factor of growth. 

Having thoroughly considered the changes in well-marked rachitic bones, 
it yet remains to describe the stage of onset and conclusion of the process. 

In regard to the initial stage of rickets there are not many reports and they 
are by no means unanimous. Spillmann describes as of primary moment the 
permeation of the vascular twigs into the cartilaginous tissue. These vascular 
twigs disarrange the cartilaginous lamellae and cause their proliferation. The 
characteristic factor of the first rachitic change, therefore, according to Spill- 
mann, is the irregularity of the line of ossification, due to the permeation of 
the vascular twigs. He attributes to the vessels the important initial symp- 
toms of the rachitic osseous changes, and it is therefore self-evident that — 
in contrast to Heubner — he adheres to the view of an inflammatory process. 
Not only in the explanation but also in the recognition of the early rachitic 
changes there are many contrasts which attain some importance when the 
question of congenital rickets is invoked. In this respect the anatomical find- 
ings of craniotabes — the first symptom of rachitis — require comprehensive 
study. 

The changes which the skeleton shows after healing of the process are better 
understood. After the zone of proliferation in the osteoid tissue is finally im- 
pregnated with lime salts and has undergone ossification, the bone becomes 
thicker, harder, distorted, and its surface beset with rough edges and osteo- 
phytes. This condition is especially distinct in the tubular bones, which lose 
their graceful contour, become heavier, and sometimes retain the shape which 
was produced in the florid stage by curvatures and infractions. Aggregations 
also occur in the cranial bones which increase the antero-posterior diameter. 
The influence upon the permanent teeth, the pelvis and the longitudinal growth 
of the tubular bones has already been mentioned. 



TREATMENT 275 

A very interesting question, although at this time obscure, is whether the 
organs of the body, as well as the skeleton, are affected in a characteristic 
manner by the rachitic process. This pertains especially to the brain, the 
spleen, the liver, and perhaps the muscles ; the frequent pathologico-anatomical 
findings in the lungs and in the heart are of a secondary nature, and in the 
digestive tract no regular form of affection is noted. It is true the anatomical 
findings in the organs mentioned are not well-defined, and are by no means 
characteristic of rickets, but the relatively common occurrence of hydrocephalus 
and enlargement of the spleen and of the liver, as well as the rare hypertrophy 
of the brain, in connection with the rachitic fundamental process cannot at 
once be ignored, although the assumption of Dickinson that these and other 
organs of rachitics show a peculiar hypertrophy of the connective and epithelial 
tissues scarcely corresponds with the actual facts. Vierordt's pathological 
findings in the musculature of the body, as already mentioned, are also scarcely 
characteristic of rickets. 

Nevertheless, as Pfaundler has recently remarked, the possibility of vis- 
ceral anomalies in rachitis in addition to the skeletal changes should not be 
abandoned. Stoltzner quite properly asserts that for this knowledge we should 
search less for morphological than for micro-chemical changes, i. e., by the 
process of staining. This method may furnish absolute proof of our view that 
rickets is a general disease, its manifestations but not its nature consisting of 
the changes in the skeleton. 



X. TREATMENT 

The question of prophylaxis can only be considered in those cases which 
are to be regarded as acquired rickets. If we accept the view of a congenital 
rachitis as well as the influence of heredity, the prophylaxis must cover a much 
broader scope and must not only influence the health of candidates for marriage 
and of pregnant women but in every case of rachitis we should endeavor to 
confer immunity from rickets to the coming generation. In practice these 
considerations are superfluous and we must attempt to protect the child from 
all deleterious influences under which rickets flourishes, no matter whether 
we admit the acquirement of the disease or an aggravation of congenital 
symptoms. 

The first attention must be devoted to nutrition and plentiful light and air. 
Even in the treatment of children already affected these factors are predomi- 
nant, therefore prophylaxis and dietetic treatment mostly go hand in hand. 

Proper nourishment of the infant has always been considered an important 
prophylactic factor in rickets and must so be maintained even though the theo- 
retic basis of this requirement has not yet been established. 

That good breast-milk fulfills this necessity of proper nourishment requires 
no proof, and its effect in weakening the hereditary predisposition to the dis- 
ease has recently been proven by Siegert. But not all breast-milk is proper 



276 RICKETS (RACHITIS) 

food and we must agree with Vierordt, who regards artificial nutrition as far 
preferable to the milk of poorly qualified wet-nurses, who are perhaps changed 
several times. Since even the best breast-milk does not protect from rickets, 
we will formulate our requirement of proper nourishment in general by plac- 
ing good breast-milk first, but that artificial nutrition is to be employed rather 
than breast-milk of a doubtful quality. That rickets is produced by too pro- 
tracted nursing has not been proven (Siegert), but owing to the deterioration 
of the milk after prolonged lactation it is not advisable. Over-feeding should 
of course be avoided in rachitic children as well as in healthy ones, but that 
gastric dilatation due to it (Comby) or chronic dyspepsia are causes of rachitis 
is unfounded. In artificial nutrition the same standard must be maintained 
as in breast-feeding, namely, that it corresponds with the generally established 
principles of nourishment of to-day. Whether the milk be sterilized or Pas- 
teurized, or whether any of the many milk preparations (Backhaus, Biedert, 
Gartner, etc.) is given is immaterial provided the necessary care is employed. 
The common fear of starches (infant foods) and the early employment of 
soups, scraped meat and eggs is no more justified in rickets than at other times. 
Without any theoretic reservations, the employment of infant foods in the first 
months of life, and of soup and meat in healthy children younger than six 
or eight months or even a year is unwarranted. Briefly, in rickets the nutri- 
tion is to be the same as an experienced physician would prescribe for any 
child. 

Of greater importance in the treatment of rickets are air and light. 1 Here 
if the circumstances permit, the physician who discovers suspicious symptoms 
in the new-born may accomplish much by ordering a large, airy room and an 
out-door life. Particularly in children who are born in the autumn and 
winter a certain amount of energy is necessary on the part of the physician to 
make it clear to the parents that the benefit of fresh air to the health of the 
child is far greater than the danger of " taking cold." Fresh air does not mean 
that the child is to be tightly wrapped and held so closely that it must inhale 
the emanations from the nurse. In bad weather the child should be dressed 
warmly and kept for some time at an open window in a heated room. If the 
room is large and bright it should not be the resort for the entire day of the 

1 Seclusion from fresh air is a more important cause of rachitis than poor feeding. 
Statistics from northern cities, in which well-to-do families house their babies 8 
months every year on account of the long duration of their winters, appear to prove 
it. On the contrary, it struck me while amongst the poor population of Naples, who 
gave their children scanty and bad food, but fresh air twenty-four hours every day, 
that rachitis was not perceptible. On the other hand, I am not prepared to say that 
" protracted nursing is no cause " of rachitis. After the sixth month of nursing when 
the stored-up iron of the liver in the baby has been used up, the milk of the mother 
begins to lack some of its needed constituents. That is why I teach the addition of a 
small amount of cereals and of an animal broth at that age. That is why I am afraid 
there is a minute degree of levity in the author's remark that " soup and meat in 
healthy children younger than 6 or 8 months or even a year are unwarranted." I 
suggest that there is a difference between soup and meat, and another difference 
between " younger than 6 or 8 months or even a year/' — Editor. 



TREATMENT 277 

family and of the seamstress, who vitiate the air. Tn any ease, it must not 
be forgotten that renewal of air is more necessary for nurslings than for chil- 
dren who are able to walk and thus can vary their surroundings. 

In well-to-do families this does not exhaust the care of children with con- 
spicuous rachitic symptoms. On the contrary, a residence in the country is 
to be chosen. The sea-coast or mountains of not too great altitude, and per- 
haps treatment with brine-baths, are advisable. 

For sea-baths the Austrian coast resorts on the Adriatic are regarded as 
beneficial, and from May to October a constantly increasing number of rachitic 
children are found there. The more important of these resorts are Grado, 
Abbazia, Lovrana, Sistiana, and Porterosa (near Triest) ; Lido, near Venice, is 
also popular. In Germany the Baltic Sea is desirable. Among the many places 
may be mentioned Heringsdorf, Misdroy, Kolberg, and Ahlbeck. The North 
Sea is less valuable for rachitics of three or four years of age. 

When a residence on the sea-coast is impracticable, regions with a sub- 
Alpine climate during the summer are no less beneficial, especially if there is 
an opportunity for natural brine-baths. In the Sanatorium for Rachitics near 
Zurich (750 meters above the sea level), to which children as young as five 
months are admitted, the results have been very favorable. In a few severe 
cases under one year, however, there were serious accidents of acclimatization 
(Hurlimann, quoted by Feer), so that it is better not to send infants and very 
delicate children at once to a high altitude, but to gradually accustom them 
to the change. In general a height of about 800 meters is preferable, but 
strong rachitics over a year old flourish in sunny regions at an altitude of 1800 
meters (Feer). 

If it is desired to combine mountain air with brine baths many well-known 
regions are at our disposal, such as Aussee, Ischl, Ebensee, Hall (in Austria), 
Eeichenhall, Berchtesgaden, Kreuznach, as well as Kosen, Eothenfelde, Suder- 
ode, Elmen, Salzungen, Wittekind and Suiza in Germany (the last quoted from 
H. Neumann). In some of these resorts there are sanatoria for rachitic chil- 
dren. However, undue importance must not be attached to natural brine- 
baths ; in dry, sunny climates of moderate altitude, artificial salt-baths will be 
sufficient. 

Among the poor, during the summer months, much stress should be laid 
on the necessity of an out-door life, although naturally in large cities the dust- 
laden air upon hot days can scarcely be regarded as a curative factor. The 
physician must make the parents understand that the expenditure of money 
for a country home for their rachitic children until they are three years of 
age is often of much greater advantage than later, when they are going to 
school. 

That much may be done for the poor in free institutions which admit 
rachitic patients for the day or permanently has been shown by the results in 
the well-known Italian institutions for rachitics (Milan, Turin, Palermo, 
Genoa, etc. ) , in seaside hospitals, as well as in the above-mentioned institution 
in Zurich. In this direction much more might be accomplished, for of late the 



278 RICKETS (RACHITIS) 

hospitals for scrofulous and rachitic children arc largely filled with those suffer- 
ing from the former affection, which precludes the admission of rachitics. Also 
the age limit of four years of some institutions excludes a number of 
florid eases. The lack of a sufficient summer vacation is certainly a factor in 
the late forms of rachitis which are particularly manifest among the poor 
population. 

Among the valuable antirachitic remedies are salt-baths, the action of 
which has been proven practically rather than theoretically understood. 

They may be given to children in the first months of life. The bath of an 
infant — 30 to 40 liters — contains about % to % kilo of salt ; in baths of 100 to 
200 liters, 1 to 2 kilos of salt. Rock salt, " Halleiner Mutterlaugensalz/' 
Kreuznacher salt, Stassfurter salt, etc., may be employed; table salt is too ex- 
pensive for such use. Some manufacturers furnish salt in compressed form 
for the bath. Coarse rock salt is often contaminated with stony elements; 
therefore it is well to dissolve the quantity intended for the bath in hot water 
so that the sediment can be retained. Where natural brine-baths are available 
they are to be preferred. 1 The stay in the rock-salt bath should be ten to fif- 
teen minutes, the temperature from 25° to 27° C. (77° to 80.6° F.). For 
older children a sponging with cool water is advisable immediately after the 
bath. More than three baths a week do not appear to be indicated, and it is 
well to follow Vierordt's rule, not to continue them for months uninterrupt- 
edly, but to give them in courses of six to eight weeks. 

At the seashore not only are sea-baths of advantage, usually with warm sea- 
water, but the pure salt air is necessary. 

Aromatic additions to the bath are alternated with the salt baths (herb and 
other medicated baths, Feldau's " Kiefermoor "). In cases of rickets domi- 
nated by anemia, iron-baths (one small Glob, martialis to a bath) or iron bog 
baths ( Franzenbader Moorsalz, % — % kilo, per bath) may be employed. 
Finally, sand-baths are very beneficial, i. e., placing the child in dry sand which 
has been well warmed by the sun. 

This dietetic treatment in the milder cases is often sufficient. 

In the drug treatment of rickets phosphorus and cod-liver oil are the most 
influential. These were introduced in the treatment of this affection by Kasso- 
witz in 1883. The theoretic foundation for their employment was furnished 
by the investigations of Wegner, who noted a more rapid consolidation of bone 
in growing animals after the administration of small doses of phosphorus. 
Upon the basis of animal experiments Kassowitz has reached the conclusion 
that phosphorus produces a local inhibition upon vessel formation at the osteo- 
chondral boundary and thus acts directly against the inflammation which he 
supposes to exist. 



a The quantity depends upon the concentration of the brine in various districts, as 
well as upon the size of the bath-tub. In Ischl 4 to 5 liters are calculated for a baby's 
bath, 15 to 20 liters for the bath of an adult, increasing by one liter per week for in- 
fants and 5 liters for adults. 



TREATMENT 279 

The prescription which Kassowitz prefers is as follows : 

Phosphori 0.01 

01. jec. aselli 100.0 

Ad. vitr. flav. 
Sig. One teaspoonful daily. 

The following prescriptions for phosphorus for the most part originate from 
Kassowitz and are especially iDdicated when there is great repugnance for cod 
liver oil : 

Phosphori 0.01 

Lipanin 100.0 

(Lipanin, which is quite expensive, may be substituted for cod liver oil 
in all of the following prescriptions. ) 

Phosphori 0.01 

01. jec. aselli 100.0 

Saccharini 0.05 

01. citri gtts. duas 

Phosphori 0.01 

01. jec. aselli 30.0 

Pulv. gumm. Arab., 

Sacchari aa 15.0 

Aq. dest 40.0 

Or, without cod liver oil. 

9- 

Phosphori 0.01 

01. amygd. dulc 10.0 

Pulv. gumm. Arab., 

Syr. simpl. aa 15.0 

Aq. dest 60.0 

A preparation which is well borne but will not keep. 

In the form of drops : 

Phosphori 0.01 

01. amygd. dulc 10.0 

01. cort. aur gtts. iv-v 

Three drops in milk three times daily. 



280 RICKETS (RACHITIS) 

For older children chocolate coated tablets of phosphorus may be given : 

Pastilli phosphori, 

Chocol. obduc aa 0.0005 

One tablet daily. 

In all of these mixtures the daily dose of phosphorus is one-half milligram ; 
more is not desirable. A 100-gram bottle will last about three weeks. The 
administration of the remedy is to continue for several months. During the 
hot season it is well to stop the medicine — except in threatening cases (laryn- 
gospasm) — and the mixture should be kept in a cool place. 

An absolutely necessary method of dispensing is Kassowitz's proposition, to 
keep an oily original solution of 0.2 phosphorus to 100 grams of almond oil, 
the mixture being dispensed in 5 gram vials. 

So much for the administration of the remedy. But what about the suc- 
cess of phosphorus and cod liver oil f We now enter into one of the most debat- 
able realms of modern therapy which develops a rather unusual circumstance, 
i. e., that, on the one side, a remedy is regarded as an absolutely reliable spe- 
cific, and, on the other, as entirely valueless. 

Kassowitz champions his remedy with great energy and does not tire of 
combating the publications opposed to his view. His absolute confidence in the 
drug is based upon his animal experiments, his rich clinical experience, the 
high praise of other prominent pediatrists, and upon the enormous popularity 
which the remedy possesses among the poor population of Vienna. To anyone 
acquainted with the conditions in Vienna it is remarkable how often mothers 
bring their children to Kassowitz's Institute with a particular request for a 
prescription for cod liver oil, and that regular attendants at other children's 
clinics prefer to pay for the medicine at the pharmacy attached to Kassowitz's 
Institute rather than obtain it free of cost from their own dispensary. It is 
also extraordinary how many prominent specialists in children's diseases favor 
and even praise the actual success of the remedy without accepting Kassowitz's 
theoretic explanation of its effect. 

Opposed to them are quite a number of physicians who are either skeptical 
or deny the value of the remedy. Among them are Henoch, Heubner, Ba- 
ginsky, Monti, H. Neumann, Comby — authorities to whom we cannot attribute 
mere prejudice or deficient faculty of observation or limited clinical material. 

The arguments which refute the action of phosphorus and cod liver oil 
are of different value. 

Least important, probably, is the objection that phosphorus is very soon 
volatilized from the cod liver oil mixture so that the child really receives a 
smaller amount than has been prescribed. Careful investigation of drugs from 
reliable pharmacies have constantly shown a positive reaction of phosphorus 
even when the bottle was uncorked for some time. However, if this were not 
the case no conclusion should be drawn against its effect, for to obtain success 
from the treatment, which is prolonged for several months, it is irrelevant 



TREATMENT 281 

whether a smaller amount of phosphorus is sufficient than was intended in the 
prescription. 

Clinical considerations are more difficult to meet. It is mentioned that the 
rachitic bony process tends to spontaneous cure; therefore, even if there has 
been improvement in the disease of the skeleton after phosphorus has been 
administered for weeks or months, the effect of the drug has not been proven. 
On the other hand, cases treated with phosphorus do not always show improve- 
ment. Finally, it is still undecided whether, in the cure of the rachitic bone 
disease, a primary influence upon the skeleton is exerted or a secondary conse- 
quence of improvement in the general condition. Unanimity on these points 
appears to be impossible, since experience is opposed to experience and views 
are opposed to views. If, for example, in a rachitic, toothless child, a tooth 
appears after the administration of phosphorus for eight or ten days, this is 
a curative effect of the remedy for adherents, while the opponents regard it as 
an accidental occurrence on account of the brief treatment. If a fontanelle 
closes after several months' administration of phosphorus some authorities be- 
lieve this to be the result of continued treatment, others the natural issue of the 
disease. Mere clinical observation of the skeleton, therefore, furnishes no posi- 
tive proof of the specific action of phosphorus and the objections of the 
opponents of phosphorus are hard to refute. 

An attempt to meet this question by another was made by Stoltzner, who 
admits the favorable effect of phosphorus upon the ossification of bone, but, 
from anatomical investigations in animals, has taken the stand that the remedy 
brings about an improvement of the osteoporosis which is present to such an 
extraordinary degree in rickets without influencing the pathognomonic osteoid 
tissue. This would prove the activity of phosphorus in strengthening the bone, 
but will not confirm the theoretic considerations which Kassowitz has attached 
to this process of healing. 

A further question concerning the action of phosphorus and cod liver oil 
is whether the cod liver oil does not have a greater therapeutic value than phos- 
phorus. It must not be overlooked that no less an investigator than Trousseau 
strongly advised cod liver oil as a remedy for rickets, that prior to the intro- 
duction of phosphorus in the treatment of this disease the advocates of pure 
cod liver oil were almost as numerous as those at the present time for phos- 
phorus. Even now the converts of phosphorus adhere to its combination with 
cod liver oil and some of them believe that phosphorus alone, without cod liver 
oil, does not completely unfold its activity. A procedure which would perhaps 
settle this question was proposed by Eey, who tested the influence in the 
rachitic child of phosphorus alone and of cod liver oil alone, and of their com- 
bination, upon the excretion of urate of calcium. It was shown that adminis- 
tration for several days of the combined remedies always increased the amount 
of calcium urate, which did not occur when the mixture was withdrawn. Phos- 
phorus without cod liver oil had no effect. Cod liver oil alone caused a slight 
increase of calcium urate. These investigations, which would indicate a special 
action of a combination of phosphorus and cod liver oil^ are unique and as yet 



282 RICKETS (RACHITIS) 

inconclusive. Vierordt, who inspired Key's investigation, warns against too 
positive deductions. 

In this wordy combat regarding the value of phosphorus as an antirachitic 
remedy two things are quite certain : the often surprising success of the remedy 
in sjxism of the glottis and the praise of the parents of rachitic children for 
the medicine. When laryngospasm which has lasted for weeks disappears after 
two or three teaspoonfuls of a phosphorus-cod liver oil mixture, and does not 
recur, it cannot be regarded as other than a therapeutic success, which is not 
lessened by its occasional failure to act — particularly in older children with 
expiratory apnea. It has already been remarked that this result is apparently 
no proof of the antirachitic value of phosphorus, but follows a direct influence 
upon the nervous system. Somewhat less conspicuous is the effect of phos- 
phorus and cod liver oil upon tetany and upon the convulsions, and still less 
upon spasmus nutans. 

The popularity and favor which phosphorus and cod liver oil enjoy among 
the poor of Vienna is certainly a factor not to be undervalued in judging their 
effectiveness. It is questionable whether a conclusion can be drawn from it 
regarding the improvement of the rachitic process, but we hear statements of a 
brighter condition, better sleep, greater activity, and this sometimes eight to 
fourteen days after the institution of the phosphorus-cod liver oil treatment. 
It appears here also that the anodyne, sedative effect of the remedy is not of 
subordinate importance, and, this quite apart from all theoretic considerations, 
is a chief factor in the popularity of the remedy. 

From these considerations it will be seen that the opinions regarding phos- 
phorus as a specific for rickets are divided. This, however, has not prevented 
its successful introduction throughout the world, and there is scarcely a chil- 
dren's hospital wherein phosphorus and cod liver oil are not prescribed by 
physicians and accepted with gratitude by the parents of the patient. There is 
probably no danger in the remedy and the recently reported cases of poisoning 
from therapeutic doses of phosphorus are too few to cause apprehension from 
its administration, especially when we consider the widespread use of phos- 
phorus and cod liver oil. It cannot be denied, however, that this medicament 
frequently has a deleterious effect upon appetite and digestion — particularly 
in children over one year of age; therefore, contrary to many opinions, the 
remedy should not be employed when there are disturbances of the digestive 
tract. Other remedies recommended for rickets are of secondary popularity. 

Cod liver oil alone, as already mentioned, is often prescribed, and formerly 
was much employed. If it cannot be taken in pure form the following emul- 
sion may be given (Friihwald) : 

01. jec. aselli 10.0-20.0 

Mucil. gumm. Arab., 

Aq. dest. aa. q. s. ut fiat emulsio . . . 90.0 

Syr. cort. aur TO.O 

One teaspoonful three times daily. 



TREATMENT 283 

There are also quite a number of preparations of cod liver oil which con- 
tain this ingredient alone (Helfenberg's sparkling cod liver oil, Standtke's pala- 
table cod liver oil, Scott's and Mellin's emulsions, Natterer's cod liver oil 
tablets), or combined with other drugs (Lahusen's iodid of iron and cod liver 
oil, Sauter's lecithin-cod liver oil emulsion, combinations with malt — Loflund, 
Liebe, Hauser & Sobotka — etc.). 

If a rachitic child is to be given cod liver oil, the most rational form is in 
combination with phosphorus. 

Calcium preparations have lost all theoretic value and appear to be super- 
fluous in the treatment of the English disease. The calcium-iron syrups which 
are still used in rachitis owe their introduction most probably to the seductive 
word calcium. 

The importance of iron in rickets is quite different. Although phosphorus 
and cod liver oil are usually employed for the pallor, in many children this 
remedy is not well borne and iron is substituted. Iron preparations may also 
be alternated with phosphorus and cod liver oil (particularly in summer). 
Finally, by those who doubt the efficacy of phosphorus in the treatment of 
rickets, iron is employed and its action is praised. The most popular form is 
iodid of iron in the following combinations : 

Syr. ferri iodid 

Syr. simpl aa 10.0 

Ten drops several times a day for children of four to seven months; 15 
drops for children of eight to twelve months; 20 drops for children two years 
old. 

Syr. ferri iodid 5.0 

Syr. simpl 20.0 

Aq. dest 80.0 

Two to four teaspoonfuls daily or malt extract with iodid of iron, y 2 to 1 
teaspoonful twice daily. 

Other preparations of iron are : 

Tinct. ferri chlorid 10.0 

Eight to 10 drops three times daily (Henoch). 

Ferri lact. reduc 0.03-0.05-0.1 

Sacch. lact 0.30 

One powder three times a day or ferratin, fersan, aloof emn, tiematogen 
(Hommel), hematicum (Glausch), iodferratose, Gude's peptomangan, and 
many others. 



284 RICKETS (RACHITIS) 

Lately sanatogen (casein with glycerophosphate of sodium) has been given 
as a food to rachitic children. 

Owing to the theoretic considerations which attribute rickets to the absence 
of some internal secretion, a number of organo-therapeutic tests have been 
made. Preparations of thyroid gland ( Knopf elmacher, Heubner), of thymus 
gland (v. Mettenheimer, Mendel), and of the adrenals (" rachitol" Stoltzner) 
have been employed without convincing results. 

Certain of the individual symptoms of rickets require special therapeutic 
consideration. 

For example, on account of the ready flexibility of the skeleton, rachitic 
children should in general be kept at rest as much as possible. Too early stand- 
ing and walking should be avoided. Eestless infants with craniotabes should 
lie on hollow cotton pads ; the bed of a child with kyphosis must be hard and 
without a pillow, or Eauchf uss's apparatus may be used ; those with beginning 
scoliosis should be carried on each arm of the nurse alternately; finally, if 
curvature of the legs develops, proper orthopedic apparatus must be employed. 

A very useful appliance is Epsteins swinging chair for rachitic children 
(manufactured by Thonet), in which the patient — properly supported by 
braces at the back, on the sides, and at the feet — is so placed that he sits with 
his face toward the support and must balance the body. 

The treatment of marked rachitic curvatures of older children belongs to 
the realm of orthopedic surgery. Surgical intervention for knock-knees or 
bow-legs should not be considered hastily, for spontaneous cure may occur as 
late as the sixth year. 

Frequently advised, but seldom utilized, is the inhalation of condensed air 
for the improvement of respiration and to compensate for the deformity of the 
thorax. 

The accompanying symptoms and the sequels of rickets require suitable 
treatment. This applies especially to diseases of the respiratory and digestive 
organs. In acute respiratory disturbances phosphorus and cod liver oil are 
indicated. That this form of medication is undoubtedly necessary for the 
nervous phenomena has already been mentioned. Only when phosphorus is not 
effective are other nervines, such as bromin, to be employed. 



INFANTILE SCROFULOSIS AND TUBERCULOSIS 

By O. SOLTMANN, Leipsic 

RELATION OF SCROFULOSIS TO TUBERCULOSIS 

Scrofulosis and tuberculosis, two inseparables ! Who can mention one with- 
out acknowledging the other ? The first is the precursor of the second — plows 
and opens the soil for it ; the relation is that of the seed and fruit to the foster- 
ing soil, of the soil from which the plant grows to the plant itself, it is a part of 
the plant, the essence of the root, its extract — and all the other synonyms which 
denote their connection and intimate relation, and which have been mentioned 
to force the general recognition of the monistic theory in opposition to the 
dualistic view. 

Nevertheless, with our deeper insight, or perhaps in spite of our deeper 
insight, of the development and nature of tuberculosis, the task of the Uni- 
tarian enthusiasts is not easy. 

Proceeding from the caseous products of scrofulosis and tuberculosis, Laen- 
nec saw in the former only a localized glandular tuberculosis. Virchow took 
a decided stand against such an opinion. He distinguished the actual tubercle 
from the irritative, inflammatory, hyperplastic processes of the tissue masses 
which originated in caseation, particularly of the lymph glands, of which scrof- 
ulosis is the chief representative. The decisive factor in tuberculosis is the 
organized cellular, non-vascular, heteroplastic new formation. It is true, even 
this undergoes a regressive, fatty, caseous metamorphosis (with a loss of its 
activity) by cell proliferation and vascular compression, but it is not limited 
to a definite pathologic tissue, on the contrary, being present in very heteroge- 
nous products. The tubercle alone decides whether or not the process be tuber- 
culosis. 

This at first furnished a new foundation for the dualistic theory. When 
the miliary tubercle, with its epithelial cell accumulation and central giant 
cells, was also found elsewhere, and its inherent specific nature could no longer 
be maintained, we gradually came to realize that the anatomical definition 
alone did not suffice for tuberculosis. The morphologic equilibrium, on the 
one hand, does not prove the essential unity, and, on the other hand, the etio- 
logic unity does not prove a similar histology. Cohnheim was the first to re- 
gard caseation and the tubercle as non-specific for tuberculosis except that 
both were the product of the tuberculous "virus," that is, that their experi- 
mental inoculation produced tuberculosis ! This placed the question of tuber- 

385 



286 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

culosis upon an entirely new footing. Instead of the humoral and cellular con- 
ception of the nature of tuberculosis or of scrofulosis, the etiologic factor — in- 
fection — was substituted. It is true, this then was not new, for there was no 
doubt of the contagiousness of tuberculosis and scrofulosis • and the inoculation 
of tuberculosis from tuberculous products, i. e., caseous glandular material, had 
long been known. The pioneer experimental investigations of Villemin — 
Buhl's law of tuberculosis as a disease of absorption — were sufficient to fasten 
the conviction of tuberculous infection, but only after the labors of Tappeiner, 
Schwenninger, Lippe, Bollinger and Cohnheim did tuberculosis as an infec- 
tious disease receive " official sanction." 

However, in all of these investigations, where was the confident criterion 
that the material employed in inoculation was actually and only the carrier of 
the tuberculous virus, and of what nature was this virus ? With the discovery 
of the tubercle bacillus by R. Koch (Baumgarten), the law of the infectious- 
ness of tuberculosis reached its final acceptance. K. Koch taught how to differ- 
entiate the tubercle bacillus from all other schizomycetes. He further taught 
how to produce pure cultures outside the body, further, the transmission into 
various animals of bacilli of several generations which showed undiminished 
virulence, and proved that all pathogenic products developed by the tubercle 
bacillus were actual tuberculosis. He again restored the tuberculous nodule to 
its proper position for the anatomist, as Cohnheim had hoped. For Koch had 
recognized that the tuberculous nodule was a true infectious tumor, that the 
miliary nodule which produced proliferated inflammation of the fixed tissue 
cells, terminating in caseous necrosis, was the product of the tissue change 
brought about by the parasite, and that it was even the first effect of the action 
and proliferation of the bacilli after their local accumulation. Koch was suc- 
ceeded by Demme, Krause, and many others, who noted that tubercle bacilli 
were present in a number of affections of the skin, glands, bones, and joints, 
which were formerly regarded as specifically scrofulous. Then the uncertain 
foundation upon which the dualists stood appeared to collapse and leave no 
question of the identity of scrofulosis and tuberculosis. 

Nevertheless, two elements were overlooked : First, in many such cases 
it was impossible to exclude, in fact it was very reasonable to assume, that the 
tubercle bacillus was now and then only an accidental host in the scrofulous 
focus ; that accordingly, when it accumulated in this region it apparently played 
but a secondary role, in that the preceding scrofulous infection had furnished it 
a point of entrance and of settlement; second, Koch himself had frequently 
failed to demonstrate, in the softened scrofulous glands, the epithelioid cellular 
nodules and giant cells, tissue necrosis and bacilli. Further, tubercle bacilli 
could not be found in the numerous peripheral, primary, circumscribed and 
diffuse scrofulous affections of the skin, mucous membranes and the glands at 
any time during their existence. I refer to conjunctivitis, rhinitis, to ozena 
and otitis,. to the various forms of scrofulous eczema, to the common tenacious 
and deep cutaneous abscesses and serpiginous ulcers, and to the fungoid, 
osseous, and joint affections which had always been regarded as tuberculous. 



RELATION OF SCROFULOSIS TO TUBERCULOSIS 287 

That the tubercle bacillus had been present in all of these affections, and 
had disappeared, is quite untenable, at least for the incipient and progressive 
processes, and the objection cannot be opposed that even in those scrofulous 
affections wherein tubercle bacilli were found the absolute proof " that these 
were originally and exclusively of a bacillary-tuberculous nature " is still lack- 
ing. Biedert adds that such a conception is impossible. 

If, therefore, it is necessary to find in the tubercle bacillus alone, or also 
in the proliferating nodules, the criterion — whether or not in a given case 
tuberculosis is present — the tuberculous nature of scrof ulosis is not yet proven ; 
then, in this sense at least, both are not identical. 

In such a decision another factor must be invoked — heredity! This to a 
certain extent represents the highest potency of infection. The belief in the 
heredity of scrofulosis and tuberculosis was regarded from ancient times as an 
axiom, based mainly upon the great number of scrofulous and tuberculous 
children descended from parents affected by these diseases. The chief exponent 
of the absolute heredity of scrofulosis was Lugol ; of tuberculosis, no less a one 
than Baumgarten. Even Cohnheim was imbued with the magic spell of the 
heredity of tuberculosis as an event which had been proven by thousands of 
experiences. Liebermeister, Nocard, Knopf, Haupt and others maintained the 
same view, and Haupt reckoned among 1,753 phthisical patients 1,197 who 
were hereditarily predisposed. Tuberculosis was therefore an eminently hered- 
itary disease. 

It is a remarkable fact that the belief in the heredity of scrofulosis became 
more prominent equally as the belief in its contagiousness declined. Quite the 
opposite was the result in tuberculosis. The better we learned to realize the 
contagiousness of the latter affection by the enormous increase of cases, the 
more did the belief in its heredity lose ground, both, I believe, with a certain 
degree of justice, as the consequence of a more thorough knowledge of the 
tubercle bacillus and its biologic properties. 

The proof of the heredity of tuberculosis presupposed that fetal bacilli and 
nodules could be demonstrated, or at least that fetal tuberculosis could be pro- 
duced experimentally. Both conditions have been fulfilled. But this is true 
only of the placental, not of germinative heredity. Johne was the first to 
demonstrate tuberculous foci, with epithelioid and giant cells, and tubercle 
bacilli in a fetal calf, these being principally localized in the liver and portal 
glands and proving unquestionably the placental source of infection. Similar 
cases were reported latter by Malvoz, Brouvier, Lungwitz, Band and others. 
Gartner and de Renzi, in their well-known experimental animal researches, 
positively demonstrated the transmission of tubercle bacilli from the mother to 
the offspring, and Gartner, in his experiments which were capable of with- 
standing the sharpest criticism, came to the conclusion that the tubercle bacilli 
frequently passed to the young from the mother, not from the father — but 
from the latter by the sperma to the mother (genital tuberculosis). In the 
human being, thus far, only the placental, not the germinative (spermatogen- 
ous, ovogenous), heredity of tuberculosis has been observed and proven, and 



288 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

must be regarded as a rare occurrence, notwithstanding all the statistics at 
hand. Scarcely two dozen cases can be found in the entire literature which 
can be designated as positive (Birch-Hirschfeld, Schmorl, Kockel, Lehmann, 
Baumgarten, Roloff and others). Lehmann at this time reported the first 
case of development of placental tuberculosis with transmission from the pars 
materna to the chorion villi, while Schmorl and Kockel were* able to follow the 
advance of placental tuberculosis from the intervillous spaces to the chorion 
villi and thereby demonstrate the course into the fetal circulation. We know, 
however, that in previously reported cases of congenital tuberculosis the pla- 
centa itself was diseased. This is important, for the placenta physiologically 
forms a filter which retains corpuscular elements and permits their passage 
only when this organ is diseased, eroded, its epithelium injured, etc. On the 
other hand, the passage is free for soluble substances, even in an intact pla- 
centa. This is all the more noteworthy since it is known that we dare not 
assume a specific infection simply by the demonstration of specific pathogenic 
agents, that the products of metabolism (toxins) of pathogenic germs of disease 
are capable of producing permanent infection (intoxication) by their chemo- 
tactic action. 

For example, we know that in tetanus and diphtheria some pathologic pic- 
ture or intoxication may be produced by the cultures of the specific and en- 
tirely destroyed attenuated bacteria, or even by preparations which have been 
made from them by means of chemistry, such as the bacteria themselves pro- 
duce in animal and man; and it is certainly correct to assume analogous con- 
ditions for the chronic infectious diseases. A certain number of what we 
to-day regard as "general nutritive disturbances, constitutional anomalies, 
diseases of metabolism and the blood " may be referred perhaps to a develop- 
ment of this kind, as hereditary habitual infectious diseases, from the fact that, 
in the soluble products of metabolism, pathogenic germs (toxins) have passed 
through the placenta and have been transmitted from the mother to the fetus. 
This perhaps is the condition in tuberculosis and would therefore give us some 
conclusions regarding the relation of tuberculosis to scrofulosis, of the mother 
— to the daughter — disease, and of the nature of the latter. If, as we have 
seen, a transmission of bacillary tuberculosis is so exceedingly rare, is it nec- 
essary to exclude a non-bacillary form? By analogy, the opposite may be 
assumed from what has been stated, and scrofulosis perhaps represents this 
non-bacillary hereditary toxic tuberculosis due to pathologic chemotaxis, which 
explains the descent of scrofulous children from phthisical parents. This 
would also make clear the great similarity of the symptoms, the wide variation 
of the course and termination, and why, in the majority of cases, scrofulosis 
terminates in recovery, but under some circumstances runs a fulminant course 
with sudden aggravation due to secondary bacillary infection, and shows an 
unfortunate outcome. The conception of scrofulosis as a non-bacillary heredi- 
tary tuberculosis gains in force from our knowledge of the action of the tubercle 
toxins. This culminates in signs of inflammatory reaction and also in 
caseation. 



RELATION OF SCROFULOSIS TO TUBERCULOSIS 289 

The experiments of Wyssokowitsch, Prudden, Vissmann, Strauss, Masur, 
Stroebe and others have shown that after the inoculation of attenuated tubercle 
bacilli a variety of miliary tuberculosis may develop which differs from true 
miliary tuberculosis only "by the deficient infectiousness." Caseous nodules 
also develop as in the local proliferation of tubercle bacilli. I must not fail 
to mention that the development of caseous pneumonia is referred to the action 
of soluble products (tuberculin), to which, to a certain extent, even a pro- 
tective action against bacillary infection is imputed. For the correctness of 
the foregoing views regarding the nature of scrofulosis and its relation to 
tuberculosis it is quite possible to obtain further support by experiments upon 
suitable animals. 

In this form of infection, what is known in scrofulosis as a hereditary pre- 
disposition to tuberculosis I would designate the hereditary diathesis, of which 
I am concerned only with the time of appearance and the nature of the manifest 
specific sequelae; how far in this process of transmission the fruit — the fetal 
organism — has at disposal protective substances, "bactericidal material (alex- 
ins), in contrast to the attacking substances (lysins) arising from virulent 
bacteria of the maternal organism." 

We may even admit, to a certain degree, a predisposition to tuberculosis in 
scrofula, in so far as it produces a favorable soil for a later accumulation, in 
contrast to the parasital heredity, which is itself of a bacillary nature 
(Lubarsch). What we term " habit " in scrofulosis is therefore the expression 
for the permanent condition, for the " habitual infectious disease " itself, such 
as is shown in its external and internal phenomena, according to age, structure 
of the body, manner of life, etc. I do not agree with Cornet, who, in his admir- 
able work upon scrofulosis — wherein he cannot deny a certain uniformity — 
attempts to differentiate two forms of scrofulosis : the tuberculous, due to the 
tubercle bacillus, and the non-tuberculous, the development of which is caused 
by other, especially pyogenic, bacteria, and to these adds a mixed form. 
Scrofulosis in itself has as little to do with streptococci and staphylococci as 
tuberculosis, diphtheria, and other specific infectious diseases, although there 
is a plentiful opportunity for the absorption of inflammatory organisms through 
the skin, mucous membrane and lymph tract, by way of the numerous local 
eruptions at the various points of entrance. That these by no means have a 
specific character corresponding to the primary disease, and that, on the other 
hand, in their symbiosis and synergesis with the specific pathogenic agents, 
they present such a destructive tendency, such a malignant life-threatening 
progression, is sufficiently well known as in diphtheria for the acute, and in 
tuberculosis for the chronic, infectious diseases. 

Such a secondary role is enacted in the case of scrofulosis, not only by pyo- 
genic organisms, but by the tubercle bacilli themselves. Cornet maintains 
that in scrofula the deleterious agent constantly finds its entrance from the 
periphery, and therefore he holds that the nature of the scrofulous predisposition 
should be referred to the periphery of the body. He does not believe in a pre- 
disposition which dominates the entire organism of the individual, but attrib- 
20 



290 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

vitis the appearance of scrofulosis in childhood mainly to the local anatomical 
relation of the protective covers with increased permeability of the skin, mucous 
membrane and lymph tract, — a condition which he designates " embryonalism." 
Hueter considers the great width of the canals, through which inflammatory 
agents may readily reach the lymph tracts and thence be transported into the 
lymph glands, as the cause of scrofula ; he regards lymphadenitis as the conse- 
quence, not as the first expression, of scrofula. The pasty, spongy appearance 
of scrofulous children is simply the result of an over-filling of the connective 
tissue and of the canals with nutritive juices. Ponfick agrees partly with Cor- 
net, partly with Hueter. He desires to maintain the conception of scrofula 
independently of that of tuberculosis. He also assumes, upon a constitutional 
basis, a pyogenic and tuberculous, and a reciprocal combination of both forms, 
in scrofulosis, wherein he ascribes the more ready invasion of bacterial germs 
to the greater richness in juices, the greater distensibility of the lymph spaces, 
the more active chemotaxis of the leukocytes, and the greater faculty of pro- 
liferation of the infantile tissue, causing on the one hand the peculiar swelling, 
and, on the other, the tendency to exudative processes and proliferative reac- 
tion, which develop the peculiar picture of scrofulosis. In how far these views 
coincide with mine is obvious. 

SCROFULOSIS 

Nevertheless, under the influence of numerous factors, which were formerly 
designated as the cause of scrofula, we may particularly understand that, 
according to the concentration and action of the chemical products of metab- 
olism of the tubercle bacilli in the blood and lymph, systems, the condition 
appears that is commonly recognized in the picture of scrofulosis as the 
erethistic and torpid habitus, by which we mean the habitus as an expression 
of the disease itself. 

Torpid scrofulosis is characterized by the coarse, thick and broad lines of 
the face, the swollen nose, the turned-up, thickened lips, the visible hyperplastic 
lymph glands upon the throat and nape of the neck, the distended obese abdo- 
men, the flabby flesh, the spongy, edematous tissue. In erethistic scrofulosis 
we note the soft, silky hair, the languid eyes, the blue sclera, the reddened 
cheeks, the bluish-white glistening teeth, the delicate skin permeated by a blue 
network of veins, the thin, delicate muscles and bones, the graceful contour of 
the body, and the slight amount of fat. The torpid form presents the charac- 
teristics of a retarded metabolism, with a sluggish, phlegmatic temperament, 
the erethistic of a greatly increased metabolism, with nervous excitement. 

And now the polymorphic varying nature of scrofulosis? How can we 
describe the local phenomena, in their common fundamental relation, better 
and more aptly than Virchow? They culminate in the vulnerability of the 
tissue with inflammatory changes of the skin, mucous membrane, glands, 
bones, and joints ; they reach their acme in the tenaciousness of their existence, 
in their exacerbations and remissions, in their coming and going, in constant 



SCROFULOSIS 291 

relapses without cause, in the multiplicity and combination of the local foci of 
the skin, mucous membranes, glands, etc. This is characteristic of the eczema, 
which appears usually over the face, on the cheeks, chin, mouth, nose, eyes, ears, 
more rarely over the hairy scalp and the trunk ; sometimes papular, sometimes 
vesiculo-pustular, at other times crustaceous and squamous, according to its lo- 
cation, and characterized by its tenacity. At the openings of the organs of sense 
the eczema may be complicated by like affections of the mucous membrane which 
sometimes extend to the eczema, or, inversely, the corrosive secretion of rhinitis 
and coryza may reach these areas and give rise to crustaceous fissures and 
swelling of the upper lip. In furunculosis of the auditory passage the eczema 
may produce a catarrhal or a seropurulent otitis which finds its way over the 
structures of the ear and causes a moist eczema rubrum upon the aural carti- 
lage with infiltration, thickening and fissures of the red, glistening skin. Fur- 
ther, in conjunctivitis the eczematous secretion which oozes from the glued 
eyelids may produce blepharadenitis, with photophobia and blepharospasm, 
and cause severe pain and bleeding fissures at the palpebral angles and over 
the cilia and eyebrows, or there may be a moist eczema of the cheeks or pustu- 
lation around the hair follicles. 

In themselves these affections of the skin and mucous membrane are not 
all specific, but their tenacity, which distinguishes them from similar affections 
which are opposed to remedial agents, their partial disappearance, or absence 
for a brief time, their unexpected return without cause in the same or an ad- 
jacent area, with a renewed tendency to attack other parts, as mentioned above, 
the implication of the neighboring lymph glands with hypoplastic swelling, 
are all characteristics which bestow to the affection its scrofulous physiognomy. 
But scrofula of the skin does not take the form of eczema alone. Acne, furun- 
culosis, lichen, even lupus and scrofuloderma, which, in part at least, are forms 
of primary cutaneous tuberculosis; also the subcutaneous cellular tissue 
abscesses with their relapses, fistulous ruptures, excavated and tenacious ulcera- 
tions, are peculiar to scrofulosis and cannot be designated as tuberculous. 
Although Demme frequently found tubercle bacilli in the scrofulous eczema 
of children we would not for this reason presuppose the eczema to be tubercu- 
lous. Only when the bacilli accumulate and proliferate rapidly, and develop 
their biological properties, are we justified in considering tuberculosis, and then 
it is a secondary cutaneous tuberculosis planted upon an eczema. 

Affections of the mucous membrane of the eyes, the ears, and the nose, the 
common tenacious forms of angina pultacea and angina pustacea with their 
pasty plugs and glassy purulent production of mucus from grooved hyper- 
trophic tonsils, the pharyngitis granulosa with adenoid proliferation of the 
nasopharyngeal space and of the hyperplastic pharyngeal tonsil, the constantly 
relapsing catarrh of the bronchi and of the g astro-intestinal mucosa, with dys- 
peptic disturbances and habitual constipation, are manifest stages of florid 
scrofula and are characterized by their great tenacity, just as are the non- 
gonorrheal sero-purulent secretions of the vagina with inflammatory infiltra- 
tion of the labia, especially in young persons. 



292 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

Affection of the glands. — The entire picture of scrofula is, however, domi- 
nated by the glandular affection which is often the first sign of the disease and 
not infrequently exists alone, without secondary symptoms. Here the acute 
inflammatory swellings known as " the concentual bubo," and regarded as a 
secondary disease, particularly in scrofula, are of less consideration in con- 
nection with hyperplastic inflammatory diseases of the skin and mucous mem- 
brane than the chronic hyperplastic swellings, independent of any local 
process of the shin and mucous membranes, which appear very much later and 
arise insidiously, without fever and without pain. They are a main charac- 
teristic of the picture of scrofula. Here, upon the basis of the above diathesis, 
we are not dealing with inflammatory swellings occurring inwardly from 
without, but with those appearing externally from within. These in the true 
sense of the word are "poison glands," true hyperplastic lymphomata with inter- 
stitial connective tissue proliferation. 

We find these peripheral glands enlarged — in contrast to the visceral 
enlargements in tuberculosis — in the nape of the neck, the jaw, the throat, 
more rarely in the axilla and inguinal region. They are often the size of a 
pea or a bean, and may attain the size of a pigeon's egg or a walnut, constitut- 
ing tumors and glandular conglomerations over which at first the skin is normal 
and movable ; later, however, the cutaneous covering is reddened and adherent 
to the gland. These glandular tumors fluctuate in size, may retrogress and for 
a long time remain unchanged, without resorption, but they invariably recur 
and slowly and insidiously undergo change, showing caseation, softening and 
pus formation, and finally rupture externally with the discharge of milky puru- 
lent material mixed with caseous flocculi. Occasionally there are sinuous fis- 
tula? due to ulceration, which heal, leaving disfiguring cicatrices with striated 
sclerotic lines in the retracted tissue. 

Under such circumstances pyogenic and other bacteria readily find a port 
of entrance, especially if there are local inflammatory eruptions in the adja- 
cent skin and mucous membranes, and it is obvious that softening and sup- 
puration of the gland is thereby facilitated. It must be emphasized that these 
entering bacteria have nothing in common with the specific primary affection, 
but they may place their definite stamp upon the secondarily infected gland. 
This is the case with streptococci and staphylococci, and also with tubercle 
bacilli. When there is an invasion of the tubercle bacilli the scrofulous gland 
also becomes tuberculous. But neither the anatomico-histologic nor the bac- 
terial findings will justify the assumption that all scrofulous glands are tuber- 
culous. 

The scrofulous osseous and arthritic inflammations which run a chronic 
course are now generally regarded as tuberculous. The fact that general miliary 
tuberculosis or tuberculous meningitis develops, often suddenly or sponta- 
neously, after trauma or following some operation attempted as a therapeutic 
measure, is certainly convincing. We know, however, of a number of pro- 
longed affections which recover under favorable external conditions ; and again, 
in a number of cases, Biedert, Kanzler, Schlegdendahl, Krause and others 



TUBERCULOSIS 293 

could find neither tubercle bacilli nor tuberculous nodules in the osseous foci 
and fungoid joint masses. Moreover, we cannot state absolutely that the 
pathologic foci in the bone, bone-marrow and joint were not originally tuber- 
culous, and were only secondarily infected by the bacilli. Henoch expresses 
the condition as follows : " The enormous growth of bone in infancy, especially 
at the epiphyses and under the influence of unknown conditions which also 
give rise to chronic inflammation in other tissues, may all the more readily 
produce a marked hyperemia and its consequences, without the early existence 
of tubercle bacilli." He refers to syphilitic affections of the bone, due to an 
unknown dyscrasic irritation, and believes that this view applies also to the 
development of bone tuberculosis under traumatic influences. 

Decide the question as we will, we cannot alter the substantive pathologic 
picture of scrofula, and at this time there is not a single convincing factor to 
combine this disease with bacillary tuberculosis. The general appearance, the 
entire course, and the termination of scrofula favor this view. For no matter 
how long its duration, often extending over many years, no matter how mani- 
fold and varying the symptoms, with periodic improvement and aggravation, 
notwithstanding the insidious relapses with the same or new local eruptions of 
the skin, mucous membrane, glands, etc., we observe neither a high-graded 
anemia nor any particular corporeal weakness; and, under any circumstances, 
I cannot admit that in scrofulous children a physical debility remains which 
may be permanent. In fact, if the external surroundings of the patient are 
favorable, we observe after a period of years, usually about the time of the 
second dentition (the sixth year) a tendency to recovery; and, apart from 
slight residua (cicatrices and defects) complete recovery is the rule, which 
would be all the more general if secondary and mixed infections were prevented 
by suitable hygienic measures and prophylaxis. Only rarely do we observe new 
local eruptions after puberty, although I must agree with Baginsky that now 
and then relapsing naso-pharyngeal catarrh, hypertrophy of the tonsil, and 
bronchitis remind us of the scrofula of childhood. 



TUBERCULOSIS 

How different the conditions in tuberculosis! Here, in contrast to 
scrofula, the numerous local phenomena are of minor importance to the consti- 
tutional symptoms. This is the more true the younger the child, and in small 
children, especially nurslings, the disease may run an almost latent course. 
Nevertheless, tuberculosis demands many sacrifices even in infancy. If we 
include the period of earliest childhood we may state positively that about 
40 per cent, of tuberculous cases show a mortality in nurslings. From the sec- 
ond to the seventh year this mortality is greater, since the local phenomena 
then became more prominent. At the period of puberty there is a decrease in 
the death-rate, but in the following years many succumb to the disease, which 
then runs the course and presents the picture of tuberculosis of adults. 



294 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

Tuberculosis of Infancy. — As already explained, it is difficult to prove the 
congenital nature of tuberculosis by the frequency of the disease in infancy. 
We to-day know that the offspring of phthisical parents are not predisposed to 
tuberculosis ; on the contrary, when the child is removed early from the environ- 
ment of such parents, it is not affected by the disease. This was recognized 
by Epstein in 1879, and explains the exceedingly small number of cases of 
tuberculosis in nurslings in the Foundling Asylum in Prague, where the tuber- 
culous mothers leave the institution as soon after labor as possible, their chil- 
dren being given to healthy women. In striking contrast is the report of 
Froebeilius of the frequency of tuberculosis in the Foundling Asylum in St. 
Petersburg where such measures are not observed — an important indication for 
prophylaxis. The overwhelming majority of cases of infantile tuberculosis are 
acquired extra-uterine, exogenous from the intimate contact with a phthisical 
mother or nurse; not, as was formerly assumed, " ingested with the milk," but 
inhaled with the respired air. The maternal atmosphere surrounds the nurs- 
ling like a bacillary spray. Because the child is so intensely and continuously 
exposed to the danger of infection it is so frequently and so readily attacked, 
and the source of the disease is more apt to be overlooked than in the older 
child whose exposure to infection is so much greater. Finally, it is manifest 
that in this daily increasing danger of tuberculous surroundings, the debili- 
tated, weak offspring of phthisical parents, who perhaps have battled in the 
womb of the mother for existence, are especially liable to infection. 

Infantile tuberculosis presents the symptoms of atrophy without local 
phenomena on the part of the respiratory tract. The innutrition, the sudden 
arrest of development, and subsequent decline of the body weight, with rejec- 
tion of food, and apathy, the disappearance of the fatty tissue, the sallow, 
wrinkled, gray skin which has lost its natural turgescence and is covered with 
flaky desquamation and frequently with intertrigo, furunculosis, and multiple 
abscesses, the thin, hard strands of muscle standing out like folds, the legs 
adducted at the knee, edema of the ankle and the dorsum of the foot, the un- 
motived dyspeptic symptoms, the mummy-like, shrunken little face, the bones 
of the skull which overlap in the form of terraces, and the hollowed fontanelles, 
the sunken eyes, the wide-drawn mouth surrounded by radiating lines — such 
is the picture of these poor little unfortunates who, without cough and without 
expectoration, but with a small, frequent pulse and atypical changes in the 
temperature which is often subnormal, are certain candidates for death. 
Seldom will we succeed in making a diagnosis from signs on the part of 
the lungs, or to demonstrate the presence of tubercle bacilli. Epstein and 
Kaufmann have found tubercle bacilli in mucus which was caught in the 
opening of a soft catheter inserted in the mouth to the root of the tongue to 
induce cough. 

Infantile tuberculosis usually runs a latent course because of its localiza- 
tion in the bronchial glands — simultaneously a proof of infection by inhala- 
tion through the respiratory tract — and the resorption of toxins from these 
isolated foci occurs so slowly, although steadily, and in such small quantities 



TUBERCULOSIS 295 

that very often instead of a febrile reaction there is an intoxication of the 
entire organism which results in marasmus and death. 

Tuberculosis of the Bronchial Glands. — Tuberculosis of the bronchial 
glands not only occurs in infancy, but, in contrast to tuberculosis of adults, 
it dominates childhood up to the twelfth year, with a tendency to rapid casea- 
tion and propagation; or encapsulation occurs and forms a secret deposit, so 
that occasionally, when other diseases — as whooping-cough, measles, influenza 
— quicken these old masses, the material which is capable of propagation is 
distributed in the organism. 

There is unanimity of opinion regarding the enormous frequency of tuber- 
culosis of the bronchial glands in infancy. I calculate its occurrence in my 
cases which have come to autopsy to be 85 to 90 per cent. In 320 autopsies 
of tuberculosis in infancy Steiner and Neuretter found the lymph glands 
affected 299 times, and the bronchial glands 286 times; Killiet and Barthez 
249 times in 312 cases. Henoch, Neumann, Seitz, Baginsky and others report 
similar findings. 

According to Weigert tubercle bacilli choose the same road as coal-dust, 
which first collects in large masses in the bronchial glands. Cornet is of the 
opinion that the rapid and early implication of the bronchial glands in infancy 
is due to the size of the lymph- vessels and tubes, to the keen energy of the 
lymph stream which is caused by the active metabolism, and to the larger 
absorption of oxygen and excretion of carbonic acid; thus the bacilli find but 
little time to accumulate in their pulmonary passage. 

Tuberculosis of the bronchial glands is not always latent. At the onset 
the glands are the size of a lentil or a bean, and when they act as a filter to 
retain the pathogenic organisms, with their immoderate and steadily increasing 
focal proliferation — and provided a generalized tuberculosis with a rapidly 
fatal course does not previously occur — when they are the size of large nuts 
or even of a fist and consist of glandular conglomerations, when they remain 
within their greatly thickened capsule and not infrequently form firm adhe- 
sions to their surroundings, then it is possible to demonstrate them by physical 
examination, and when they surround air canals, vessels and nerves we may 
form a correct opinion of the disease by pressure phenomena. Apart from a 
circumscribed dulness about the size of a silver dollar laterally from the manu- 
brium sterni at the sterno-clavicular articulation, noted by some authors, espe- 
cially upon swelling of the retro-sternal glands, which are often implicated, the 
central stock of bronchial glands which surround the bifurcation in the form 
of a heart, is of particular importance in the diagnosis. Here there may be an 
intrascapular circumscribed area of dulness at the height of the third to the 
fifth thoracic vertebra, together with increased bronchial respiration, or a dis- 
tinct stridor with air hunger and dyspnea, thus betraying the presence of these 
glands. In like manner do the deep mediastinal glands which ascend as a part 
of the central stock of the bronchial glands, by surrounding and embedding 
the cava, the vagus and the recurrent laryngeal nerves, lead to cyanosis and 
edema of the face, or to periodic paroxysms of cough as in the case of per- 



296 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

tussis, or, simulating a foreign body in the trachea, there may often be simul- 
taneous asthmatic attacks, palpitation of the heart, paralysis of the vocal cord, 
etc. Where only a few of these symptoms appear, which do not permit of any 
other mode of origin, and are accompanied by constitutional phenomena, their 
presence is of great diagnostic importance, especially when the deep glands of 
the neck and subclavicular and intercostal glands are palpable, and I must em- 
phasize the fact that by this means I have frequently made a correct diagnosis 
during the life of the patient. 

Pulmonary tuberculosis in infants shows many peculiarities as compared 
with the same affection in adults. After puberty phthisis is the most frequent 
from of tuberculosis, the lung usually being primarily affected with the point 
of attack at the apex and predominated by miliary nodule formation. In the 
child pulmonary tuberculosis is less common than tuberculosis of the bronchial 
glands ; it is usually secondary, beginning with glandular affection. The lower 
lobe is first attacked, the apex often remaining exempt. As in the bronchial 
glands here also caseation predominates ; the formation of circumscribed inhibi- 
tive indurative masses which prevent the progress of the process does not occur 
or is incomplete. Pulmonary tuberculosis in the adult remains localized for a 
longer time. In the child the pleura and pericardium are implicated early; 
the appearance of miliary nodules with the formation of caseous masses in the 
visceral glands, liver, spleen, kidneys, is the rule. 

In older children the affection of the apex is often the first demonstrable 
sign of tuberculosis, for here the condition is the same as in the adult in that 
the disease is not due to an obsolete tuberculous focus which has retained its 
virulence from infancy. The apex of the lung is the point of least resistance 
because of its slight respiratory excursus; the entrance of the bronchi of the 
apex into the main bronchus occurs in an obtuse angle, ventilation is difficult, 
and germs which have once found their way into this region do not easily 
escape; the tubercle bacillus therefore has time to accumulate here — in inocu- 
lation experiments it requires from ten to fourteen days — especially as the 
emptying of the pulmonary veins is difficult, the circulation inhibited — in a 
sedentary life there is even forced torsion — so that stagnation of the secretion 
is the natural consequence. In young children, particularly nurslings, the con- 
ditions are quite different. Here the heart dominates the thorax, the lungs are 
still deficient in breadth and develop outward anteriorly only with the increase 
of the osseous transverse diameter; the apices lack the fine branching of the 
bronchi, and the larger air canals are broad. Posteriorly the extensibility of 
the thoracic walls laterally to the vertebral column is slight, respiration is in- 
complete, and the secretory stagnation is influenced by the recumbent posture. 
It is true, in the first years of life the lower border of the thorax does not in- 
crease during inspiration, but lessens on account of the lack of power of the 
thin, yielding, elastic ribs to maintain an equilibrium with the marked tugging 
of the diaphragm, and this is all the more conspicuous in debilitated older 
children who are subject to catarrhal affections, infiltration and rachitis. 
Therefore the current of air which contains bacilli is directed to the glands near 



TUBERCULOSIS 297 

the hilus and the bacilli embed themselves firmly in the pulmonary tissue 
directly in the broncho-pulmonary glands. % 

The distribution of tuberculosis from the bronchial gland occurs also by 
contiguity (periglandular tuberculous pneumonia), by way of the lymph tract 
(peribronchitis caseosa, caseous pneumonia) , by way of the circulation, directly, 
by adhesion to the walls of the vessels, erosion, rupture into the lumen of the 
vessels (infectious embolism), or indirectly, by bacillary deposits in the tho- 
racic duct (hematogenous, localized, general miliary tuberculosis). Thus, clini- 
cally as well as anatomically, we have three well characterized forms of pulmo- 
nary tuberculosis: acute miliary tuberculosis, subacute caseous pneumonia, and 
chronic disseminated infiltration. The principal representative of infantile 
pulmonary tuberculosis is caseous pneumonia, but the three forms present only 
gradual differences; they are often combined, or one form encroaches on an- 
other. 

Miliary Tuberculosis. — Miliary tuberculosis occurs usually in connection 
with vascular tubercle. Cornet believes that the greater frequency of this form 
in young children is due to the fact that the bacterial toxins permeate the deli- 
cate vascular wall quicker, and are carried away more rapidly because of the 
active circulation, without leaving local irritative phenomena ; obliteration and 
occlusion do not occur; the bacillus which follows, therefore, may rupture the 
delicate vascular wall, and this would happen all the more certainly if the 
starting-point were not so often in the gland, whereby to a certain degree, an 
encapsulation and retention of toxins is permitted. When, however, the inva- 
sion occurs by means of trauma, mechanical injury such as from whooping- 
cough, etc., the bacilli are enclosed in leukocytes under proruption of miliary 
nodules and rapidly deposited in all organs. If death occurs early we find 
fresh small nodules; if, however, the irruption occurs slowly, gradually, in 
exacerbations, the course is then protracted, and we find the nodules mostly 
undergoing caseation in the lungs, also in the visceral glands, the serous mem- 
branes, bone-marrow, meninges, etc. In the first three years of life often a few 
days suffice for the termination of this process; in older children the affection 
may last three or four weeks. Recovery is scarcely possible. The symptoms 
seldom give positive diagnostic support. Here also the general phenomena due 
to the toxins are the most prominent. Atypical high fever, occasionally sub- 
continuous temperature which ranges as high as 41° C. (105.8° F.), or the 
intermittent or the inverse type, or subnormal temperatures which continue 
for several days, always with a rapid pulse (180 per minute) and increased 
dyspneic respiration (40 to 60 per minute), stupor and apathy, indifference to 
the surroundings, rapid and extensive emaciation and complete exhaustion, en- 
largement of the spleen, petechia? upon the skin, especially in the abdominal 
region, constitute the chief diagnostic criteria in contrast to the negative physi- 
cal signs on the part of the lungs. The presence of bacilli in the blood and in 
the cerebrospinal fluid, and of miliary eruptions in the chorioid, is exceptional. 

Caseous Pneumonia. — In contrast to the preceding affection, only rarely 
does the diagnosis of caseous pneumonia in children cause perplexity. The 



298 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

demonstration of bacilli is not necessary for the recognition of this disease. 
Here it is particularly evident that physical diagnosis has not only lost nothing 
of its former importance but is of special value, for it is not only necessary 
to make a diagnosis, but to decide the stage of the disease — how far in each case 
the affection has advanced. We do not treat the disease, but the patient; " the 
individual must be kept within the horizon." Usually we find general symp- 
toms at the onset. No matter whether the disease appears after acute catarrh 
of the bronchi, after pneumonia, measles, whooping-cough, or otherwise, there 
has not been complete recovery from the preceding affection ; the former health, 
color and activity of the child are lost, it tires readily, does not care to play, and 
becomes apathetic and melancholy. The increasing pallor, the poor appetite, 
the emaciation are unmistakable signs of retarded nutrition. Catarrh now 
appears with cough, as the result of a constant implication of the bronchial 
tree. This may for a time disappear, but recurs with renewed severity and 
becomes obstinate and persistent. The child complains of pain in the chest, 
which is increased by palpation ; upon auscultation we hear pleuritic friction, 
rubbing, gurgling, or rales, distributed everywhere, above, below, upon the 
right, upon the left. The expectoration is profuse, the sputum purulent and 
blood-streaked. The respiration is rapid and dyspneic; subcrepitant rales be- 
come distinct ; the dulness, which at first is limited, gains in extent ; bronchial 
respiration and moist, crepitant rales persist in the same area which presents 
a tympanitic percussion note. Briefly, with tormenting cough, night sweats, 
hectic fever, diarrhea, and emaciation, the signs of increasing infiltration, or 
inflammation of the finest bronchi, of destruction, of cavity formation, become 
distinct. Even at this stage there may be an arrest of the process, especially in 
older children, if, similarly as in adults, there is circumscribed reactive periph- 
eral inflammation with the formation of new connective tissue which leads to 
encapsulation of larger areas, with induration, contraction, and extensive bron- 
chiectasis. The fever, which is due to toxins and entirely uninfluenced by 
drugs, may become less marked or disappear, provided the organism is able 
to produce bactericidal substances. 

Nevertheless, the phthisical habitus becomes manifest. The expiratory 
position of the thorax with a vertical relation of the ribs, deepening of the 
intercostal spaces, the acute epigastric angle, and the flattened anterior surface, 
the retracted grooves at the neck and the smallness of all diameters, the de- 
creased respiratory area, the winged scapulae are all much more manifest than 
is usual in the adult. After a brief period of quiescence or apparent improve- 
ment the symptoms are exacerbated and, provided cardiac insufficiency or men- 
ingitis has not hastened the fatal issue, death approaches in a slow, dragging 
tempo, with the picture of toxin cachexia and usually without the formation of 
extensive new foci. The extreme pallor, the hectic fever, with changes of tem- 
perature from 34° to 40° C. (93.2°-104° F.) in a day, bilious vomiting, the 
colliquative intestinal symptoms with distended abdomen and effusion into the 
abdominal cavity, the edema of the extremities with obliterating thrombosis, 
the meningeal symptoms, occasionally with marantic cerebral sinus thrombosis, 



TUBERCULOSIS 299 

the stigmata and petechia?, the bed-sores, with rapid emaciation and atrophy 
which expose the contour of the skeleton, the prominence of the malar bones, 
the eyes deeply sunken in the hollowed orbits, the prominent clavicle and scap- 
ula, and spinous processes of the vertebra, and the distinct outline of the pel- 
vis, conclude a scene of misery which can be better depicted with brush and 
palette than with pen. 

Tuberculous Meningitis. — Tuberculosis of the lungs is usually a secondary 
affection in childhood — primary cases are extremely rare (Demme, Hammer, 
Wassermann, and others) — and usually develops from a focus in a bronchial 
gland. Quite the reverse, however, is the rule in tuberculous meningitis, the 
so-called basilar meningitis being particularly frequent in infancy in the pro- 
portion of about 60 per cent, to 8 per cent, in adults. The predisposition of the 
meninges to disease in infancy is due to the " affinity of the tissues for water," 
whereby the meningeal mesh-work is constantly surrounded by a fluid rich in 
albumin and nutritive salts, which forms a particularly favorable culture 
medium for pathogenic organisms. Therefore in the first three years of life 
the brain increases to almost four times its weight at birth, while in the re- 
maining years it enlarges barely one-sixth of its entire mass (at birth 13 to 14 
per cent, of the total body weight, in adults only about 2.5 per cent.), which is 
proof of the enormous amount of labor produced by the increased metabolism 
and richness in blood. According to my experience no importance can be 
ascribed to heredity in the development of meningitis. Tuberculous meningitis 
owes its origin mostly to an old caseous focus in the bronchial glands (lungs, 
joints) from direct rupture into the circulation, as in the case of miliary tuber- 
culosis ; only in exceptional cases does it arise by contiguity from a neighboring 
caries of the bones of the skull (petrosal bone, the nose). In favor of the 
hematogenous development is the anatomical formation with its nodular swell- 
ings in the course of the vessels, and this also explains the simultaneous erup- 
tions in other organs. 

The diagnosis of tuberculous meningitis in adults is usually very difficult, 
provided lumbar puncture fails to reveal the true nature of the disease, but in 
infancy the symptoms are so typical and almost invariably recur with such un- 
mistakable uniformity and regularity that, in the absence of other tuberculous 
phenomena, they might be designated as pathognomonic, and simultaneously 
permit a differentiation from meningitis simplex (convexitatis) and cerebro- 
spinal meningitis. The individual symptoms do not arise suddenly and ful- 
minantly, as in the former, with loss of consciousness, associated with delirium 
and general convulsions, or, as in the second affection, with chill, vertigo, vom- 
iting, pain in the limbs, cutaneous hyperasthesia, herpes facialis, enlargement 
of the spleen, and implication of the organs of sense, but the onset is gradual 
and insidious, corresponding to the exceedingly chronic infection and true to 
the anatomical localization and distribution of the process to the base of the 
brain. As in embolic processes due to organic disease of the heart, so here also 
does the hematogenous invasion follow the basal vessels to the bed of the 
arteria fossce Sylvii. The gelatinous exudate, permeated with miliary tubercles, 



300 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

surrounds the basal portions of the pons and chiasm in masses of varying size, 
forms anteriorly to the olfactory lobe, implicates the medulla oblongata and 
cerebellum posteriorly, and internally passes into the Sylvian fossa, follows all 
of the vessels, and is accompanied by detached or firmly grouped chains of 
transparent or opaque miliary tubercles which are not only found in the reti- 
form tissue but also permeate the nerve substance, and even encroach on the 
trunk ganglia as far as the convexity. The ventricles are dilated and filled 
with exudate, the ependyma is granulated and thickened, the chorioid plexus is 
swollen and absolutely choked. Often, especially in protracted cases, as I have 
convinced myself, the membranes of the spinal cord are affected similarly as 
those of the brain. 

Prior to the actual outbreak of the disease, as a rule, the discoloration of 
the skin, the deficient nutrition, and the increasing emaciation are conspicuous, 
especially upon the trunk and extremities, which present a distinct contrast 
to the round, full, bright face. The disease begins with severe spontaneous 
vomiting which may recur several times in the course of the affection ; it is not 
attended with nausea, occurs independently of the ingestion of food, is usually 
forcible or projectile and appears suddenly and unexpectedly upon change 
of posture, or when sitting upright (cerebral vomiting). The pulse, the tem- 
perature, and the respiration, which at first were abnormal, fall to lower levels. 
Pressure of the basal exudate and the ventricular effusions cause irritation of 
the nerves at the base of the brain, particularly the pneumogastric. This ex- 
plains the apparently altered respiration, which is slowed, deepened and inter- 
rupted. Frequently, after a brief arrest of respiration, there is a deep, sigh- 
ing, labored breath, as though the child had a heavy weight upon its chest. 
The pulse decreases with the respiration and sometimes falls below 60 or even 
50 per minute. The temperature also declines, so that in the three continuous 
curves of respiration, pulse and temperature there is quite a uniformity which, 
I agree with Heubner, is of great importance. 

Pressure of the exudate upon the chiasm, etc., soon causes ocular symptoms. 
The eyes are rotated upward, frequently with their axes diverging, thus mak- 
ing more gruesome the peculiarly rigid and serious facial expression, and, with 
the furrowed forehead and the head bent backward, they lend to the counte- 
nance something superhuman, something outside our ken. Consciousness is 
usually retained. When sitting in bed, or when standing, there is a distinct 
sensation of vertigo. When the patients are recumbent and apathetic their 
arms are frequently crossed over their heads and the hands pick at the hair and 
lips. In consequence of collateral hyperemia a fleeting erythema frequently 
crosses the face which, like the other symptoms, such as slowing of the pulse, 
vomiting, headache, vertigo, is to be regarded as a pressure phenomenon of the 
brain due to limitation of space in the cranial cavity. The abdomen is re- 
tracted and there is obstinate constipation. Contraction of the muscles of the 
neck, retraction of the head, trismus, and gritting of the teeth are well marked, 
as in simple meningitis. With the ascent and with the increase of the exudate 
and the implication of the motor areas by irritation, torsion or compression of 



TUBERCULOSIS 301 

the nerves upon their passage through the tense cerebral membranes, disturb- 
ances corresponding to the frequent change of irritation are noted, such as 
headache with convulsions, and facial paralysis which is usually partial. Stra- 
bismus, ptosis, contraction and distortion of the angles of the mouth also occur, 
with obliteration of the naso-labial fold — rudimentary, varying, fleeting — until 
finally, with the picture of general paralysis, and with a tired, worn, vacant 
facial expression and dulled consciousness, a rapid pulse, increased respiration 
and a renewed rise of temperature — occasionally with a brief return of con- 
sciousness which is often illusive — without a struggle, life quietly ebbs away. 
Tuberculous meningitis usually runs its course in fourteen days to three weeks ; 
only rarely is there a deviation from the above type ; then the onset is stormy, 
with fulminant symptoms and without essential prodromes, and the case ter- 
minates fatally in a few days ; or, on the contrary, the disease may last for 
more than six weeks with focal symptoms such as occur in connection with 
tuberculosis of the brain — solitary tubercle in the cerebellum, trunk ganglia, 
medullary layer, cortex. In the latter condition, especially in older children, 
definite psychical depression becomes prominent : confusion, verbigeration, de- 
lirium — conditions of excitement which are intermittent and run their course 
with hallucinations, fear, speech disturbance, deafness, and blindness, and may 
then closely resemble the typical psychosis of adults. 

Intestinal Tuberculosis. — While the forms of infantile tuberculosis here- 
tofore described are distinguished by their frequency, as well as by their varia- 
tion in typical form and course from the tuberculosis of later life, the tubercu- 
lous diseases of other organs are mostly secondary in this respect. This is 
especially true of the digestive tract. Earely are the pharynx, soft palate, and 
uvula involved; the pharyngeal tonsil (adenoid vegetations), tonsils, tongue, 
etc., are seldom implicated (Piffl, Gay, Siegert, Friedmann, and others), and 
even less commonly the stomach. The frequency of tuberculosis of the intesti- 
nal tract is also greatly exaggerated, as was mentioned in the description of 
nursling tuberculosis. There may be primarily a true "feeding tuberculosis" 
due to the ingestion of food which contains bacilli (milk of a phthisical mother 
or wet-nurse or of the cow, meat) or to the use of the same spoon or other eat- 
ing utensil by a phthisical nurse ; but much more frequently the disease arises 
secondarily by swallowed sputum which contains bacilli, or by autointoxication 
from some other organic focus by way of the lymph tract or circulation. With 
preference for the region of the ileocecal valve the infection is usually localized 
in the Peyer's patches and solitary follicles after caseation of the miliary nod- 
ules, with infiltration and with crater-like, annular ulcers which girdle the 
transverse axis of the intestine, invade deeply to the serosa, and may lead to 
performation likewise as in adults. In my cases which have come to autopsy a 
rinding of this kind was rare. Anemia, emaciation, complete loss of appetite, 
often with burning thirst, atypical fever, severe peritoneal irritative phe- 
nomena, such as tearing colic with the diarrheal discharge of greenish, mucoid 
dejecta, or fatty stools of a light yellow, glistening, nodular appearance which 



302 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

will not yield to any medication, are common recurrent symptoms, which, ac- 
cording to the intensity and extent of the local affection, may last for months 
or years and even until death, which, however, may occur surprisingly early 
from a generalized tuberculosis or after perforation due to peritonitis. 

Tuberculous Peritonitis. — No matter whether tuberculous peritonitis be an 
accompanying phenomenon of general miliary tuberculosis without reaction, 
and of no interest clinically, or a circumscribed peritoneal tuberculosis origi- 
nating from an intestinal ulcer, or a chronic exudative diffuse tuberculous peri- 
tonitis, the symptoms coincide with those of the same disease in later life. 
Pain upon pressure, spherical distention of the abdomen, particularly the um- 
bilical region, palpable resistance and strand-like thickenings, or agglomerated 
tumors caused by the adhesion of intestinal loops, painful vomiting preceded 
by severe nausea, and clay-like, fatty stools may suggest the diagnosis. If re- 
covery follows we may assume that we were dealing with a non-tuberculous 
chronic peritonitis such as has been described by Galvagni, Henoch, and others, 
or early laparotomy may have been responsible for this favorable termination. 
The explanation of this condition is disputed ; whether the intra-abdominal de- 
crease of pressure combined with improvement of the circulation, whether the 
neoplastic contracting cicatricial tissue, or the atmospheric air is the favorable 
factor, has not been determined. The elimination of pathogenic bacilli and 
their toxins, which results in the removal of the exudate, may play a large 
part in this, as also perhaps the reactive inflammation brought about by lapa- 
rotomy. Ingianni has recently produced aseptic peritonitis in animals by the 
intraperitoneal injection of alcohol, which renders them immune to tubercu- 
losis, and he regards the acute peritonitis and marked phagocytosis after opera- 
tion as the cause of recovery from the disease. 

Tuberculosis of the Mesenteric Glands. — This affection, sometimes called 
tabes mesenterica, which is often intimately related to tuberculosis of the intes- 
tine and peritoneum, frequently causes diagnostic perplexity from the fact 
that the enlargement of the glands can rarely be demonstrated . by palpation. 
The mesenteric glands are attacked much less commonly than the bronchial 
glands, in the proportion of about 1 to 20. 

Tuberculosis of the liver, spleen, kidneys, genitalia, and the skin presents 
no special peculiarities in children and therefore will not be discussed. 

Tuberculosis of the Bones and Joints. — This localization of tuberculosis 
assumes such a predominant part by its frequency even in earliest childhood, 
and is of such essential surgical interest, that a special chapter will be devoted 
to it in the volume on surgery. I have already alluded to its relation to 
scrofula. Here it need only be emphasized that the implication of the bones 
and joints is often the first manifestation of tuberculosis in infancy, either pri- 
marily, which is rare, or secondarily by metastasis from an old focus, although 
among 67 cases of tuberculosis of the bones and joints. Orth was unable in 14 
instances to find any originating focus. 

In the three varieties, designated by Konig granulation tuberculosis, tuber- 



TUBERCULOSIS 303 

culous necrosis and infiltrated tuberculosis the affection may occur in all bones 
of the skull, the face, the trunk, or the extremities, in isolated or multiple foci, 
although certain bones are especially prone to the disease, such as the long 
tubular bones and vertebral bodies.. The affection often leads to rapid case- 
ation, caries with softening, abscesses, or necrosis, with sequestration which, 
from its wedge shape has been alluded to by Volkmann and Konig as " tuber- 
culous infarct " in proof of its embolic nature, which has also been verified ex- 
perimentally by W. Muller. Apart from the great predisposition, which causes 
the rapid growth of bone and a particularly favorable circulatory relation, trau- 
matic influences evidently play an important role in the frequency of bone and 
joint tuberculosis, since boys are affected twice as often as girls. Schiiller, 
Muller, and Krause have confirmed this in their experiments. Krause assumes 
that slight injuries which produce no decided irritation or succeeding symp- 
toms are more important causative factors than abrupt and severe injuries, be- 
cause, during recovery from the latter, the reactive tissue formation is so ener- 
getic that the tubercle bacilli cannot withstand it. This conclusion coincides 
with the experimental finding that miliary tuberculosis occurs much more 
rarely in chronic, caseous, tuberculous pneumonia with connective tissue pro- 
liferation, under formation of indurative fibrous masses and retraction of 
tissue, than when tuberculosis runs its course in early life without these periph- 
eral reactive inflammatory processes. When, as in spondylitis with simulta- 
neous destruction of the ligamentous masses, there is an extreme tendency to 
suppuration, which represents the product of tuberculosis of the vertebra, 
the pus does not remain in the focus but wanders into strange territory as a 
gravitating, congestive abscess. This pus formation has nothing to do with 
gravitation but, independently of the law of gravity, follows certain tracts, 
which are defined by anatomical arrangement of the tissues, into a preexisting 
space such as has been formed by interstices of the loose cellular tissue which 
unites or separates the organs, surrounds them, or permeates them. The dis- 
tribution of the abscess depends upon its distensibility and regional arrange- 
ment — varying according to the localization in the cervical, thoracic or lumbar 
portion of the vertebral column. Similar conditions exist in tuberculosis of 
the joints, which is commonly propagated from the bone by rupture of an 
osseous focus in the synovial cavity (Volkmann), with exudation and tendency 
to destruction of the synovial membrane and caseation and disintegration of 
the cartilage of the joint. In the further course of the disease there is an in- 
volvement of the soft parts, with swelling and the formation of caseous granu- 
lation foci in the muscles and in the intramuscular and subcutaneous tissue, 
with numerous circumscribed or extensive abscesses and many entangled fis- 
tulous sinuses. Wherever the reactive inflammation tends to limitation, the 
new bone formation (osteosclerosis) and connective tissue proliferation permit 
healing, although usually with circumscribed defects and remaining defor- 
mities. Notwithstanding the limitation and encapsulation, naturally we have 
no assurance that quiescent germinating material does not remain. 

Tuberculosis may involve all joints, but some articulations are especially 



304 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

predisposed. In contrast to adults, in the child the hip, the knee, the foot, 
the elbow, in their order of frequency, are attacked, and here the osseous origin 
of the disease is especially prominent. Lannelongue asserts that among 100 
cases of tuberculous coxitis about 70 per cent, occurred in the first ten years 
of life. The anatomical relations of the hip-joint, the processes of growth, 
the comparatively late ossification of the head of the bone, trochanter and 
pelvic floor, the intracapsular location of the neck of the bone, and the great 
circulatory richness of the joint give us an explanation of the overwhelming 
frequency of coxitis in youth. Karewski states that among 999 cases of infan- 
tile tuberculosis of the joint 365 cases, i. e., 37 per cent, were coxitis. 



PROPHYLAXIS AND TREATMENT 

No matter in how far we acknowledge the relationship of scrofula and tuber- 
culosis, they participate in a common therapy. The combat of those plagues 
which attack the marrow of the nation is to-day justly regarded in our civil- 
ized countries as one of the most important labors of state hygiene and social 
reform. From this standpoint, at the last Congress for Combating Tuber- 
culosis as a National Disease special attention was devoted by the most eminent 
authorities to the value and benefit of hospitals at springs and at the seashore 
as a most important prophylactic measure for diseased children, and to the 
necessity of establishing sanatoria for the tuberculous, and homes for the non- 
tuberculous who are predisposed to this affection by their origin and surround- 
ings. The constantly widening circle of this land plague has convinced both 
experts and the laity that notwithstanding all endeavor, study and investiga- 
tion, we are unable successfully to combat tuberculosis with any remedy in our 
materia medica ; but we have attained a clearer understanding of the manner 
of infection and have learned especially the sources of tuberculous infection in 
infancy, and now the battle must be waged anew with the reinforcement of 
hygienic prophylaxis. Naturally, this must begin with infancy, for here is 
the so-called "family predisposition," from which "family infection" (Heub- 
ner) originates. Notwithstanding the widely distributed educational effort, 
both spoken and written, in regard to the great danger of tuberculous infection, 
the restriction of the marriage of tuberculous persons will remain a pium 
desiderium, and the removal of the infant from tuberculous parents will not 
be accomplished usually from inepta parentum charitas (unprofitable parental 
love) ; but we must not cease to demand such a sacrifice and to see that it is 
carried out wherever possible. The least requirement is that the phthisical 
mother must not nurse her child but give it to a healthy wet-nurse. The infant 
should not share the same bed-room with the mother; it should be protected 
from kissing; the tasting of the child's food by the mother is to be prevented, 
and suspected brothers and sisters kept away. Tuberculous servants, nurses 
and governesses should be excluded from the house. Hygienic cleanliness of 
the child and its surroundings must be enforced as soon as possible. Atten- 



PROPHYLAXIS AND TREATMENT 305 

tion should be devoted to the care of the skin, the mouth, the nose, the ears, 
the anus and genitalia; the nourishment of the child should be according to 
modern dietetic methods. Milk — the best exclusive or principal food of chil- 
dren in the first years of life — must be of unquestioned quality and preserved 
by boiling or sterilization in the house of those who consume it. This precau- 
tion is especially necessary, as the milk of tuberculous cows is the carrier of 
tubercle bacilli, and there is no law which restricts the sale of infected milk 
and milk products. According to Siedamgrotzky, Bang, Ebert, Jacob and 
other investigators, the result of the reaction of the tuberculin test in cattle 
is distressing, and shows the importance of the question for infancy in that 
the milk of cows that react to tuberculin is always suspicious. Bang has 
shown that the calf which is removed from the mother cow and fed upon 
boiled milk does not become infected but remains free of tuberculosis. Upon 
this fact, with the aid of the tuberculin test for diagnostic purposes a systematic 
method of extinction for the control of bovine tuberculosis is dependent. 

Antituberculotic prophylaxis, as already indicated, is not to be limited to 
infancy; a strict watch must be kept over the cribs and nurseries, kinder- 
gartens, play-rooms, schools, orphan asylums, hospitals, and other institutions, 
and a strict control of the health of those children who are sent to the coun- 
try during the holidays is necessary for the protection of others who are well. 

A proper nutritive therapy must be instituted in infancy in children who 
are suspected of being scrofulous or tuberculous, or who present manifest 
symptoms of tuberculosis. Here the nutritive remedies are curative and the 
curative measures must be nutritive. In this respect milk again occupies the 
first place. Milk foods, buttermilk, sour milk and cream with cacao, cacao 
to which some vegetable has been added, and barley coffee are excellent foods. 
Mucilaginous soups with bouillon and Leube's meat solution, or with boiled 
meat, preferably white meat, pigeon, chicken, veal in the form of puree, game, 
roast beef, boiled ham, tongue, and beef minced or chopped up with butter, 
with rye bread; at mid-day, after the meat, some young vegetables which does 
not cause fermentation, such as peas, beans or spinach, with potatoes, some 
light starchy food, and wine gelatine are permissible. Sweets, biscuits, cakes, 
chocolate, delicatessen, hard eggs, wine — particularly the sweet southern wine 
such as Malaga, Madeira, sherry and port wine, which often reach the con- 
sumer in very questionable quality — are strictly prohibited. We must not be 
content to prescribe the food under such general terms as " strengthening diet, 
etc.," but the quantity and quality and the time of meals should be given for 
the little patients in writing. 

Special attention must be given to the salubrity of the dwelling, particularly 
of the bed-room. Sunlight and air are the greatest enemies of the bacillus; 
damp, dark, poorly ventilated living-rooms are its breeding places. 

The important curative factors therefore are sea-baths, with sunshine, fresh 
air, and a salty ocean breeze which acts as a cleansing broom. But in the 
choice of a suitable region the general constitution and the individuality of 
the child must be considered. 
21 



306 INFANTILE SCROFULOSIS AND TUBERCULOSIS 

The Baltic Sea, a closed basin which partially freezes, with a strong influx 
of cold, sweet, river water in the spring, and therefore with a less amount of 
salt and a lowered temperature, and without tide and waves, is serviceable in 
the late summer for erethismic scrofulous children and those suspected of tuber- 
culosis; Cranz, Zoppot, Colberg, Misdroy, Swinemunde are the milder, Sass- 
nitz, Binz, Doberan, Travemunde the more invigorating regions. Delicate, 
anemic and irritable children should at first take only warm sea-baths. The 
open North Sea with the warming influence of the Gulf Stream, a greater 
amount of salt, with its ebb and flood and larger waves, is more suitable for 
torpid scrofulosis. This affection requires greater warmth, more stimulation, 
and here the effect of a maritime climate is much more marked. Sylt, Wyk, 
Amrum, Langer Oog and Wangerog, Norderney, Yuist and Borkum, Scheven- 
ingen, Blankenberge, Ostende, are preferable according to the individual condi- 
tions. Sanatoria and hospitals, open throughout the year, must attain larger 
accommodations and better arrangements for bathing and for the aid of chil- 
dren in straitened circumstances. Patients of means may go to the beautiful 
winter stations on the Adriatic and the Eiviera, or to the east coast of England. 

In addition to sea-baths, brine-baths — often combined with the internal 
use of mineral spring waters which contain chlorid of sodium, iodin, or bro- 
min — exert an excellent action in scrofula and tuberculosis, particularly when 
there are accompanying chronic affections of the skin, enlargement of the 
glands, inflammation of the bones and joints, with their sequelae ; in these con- 
ditions the brine-bath may be strengthened with lye. Erethismic natures re- 
quire mild brine-baths, torpid temperaments the stronger baths. When there 
is a tendency to catarrh of the mucous membranes those brine-baths should be 
employed which include methods for graduating the strength of the brine. The 
number of brine-baths is enormous. Diirrenberg, Kosen, Salzungen, Hall, 
Hallein, Heilbrunn, Soden, Ischl, Aussee, Berchtesgaden, Reichenhall, Kreuz- 
nach, Krankenheil-Tolz, Nauheim, Oeynhausen are but a few. 

The symptomatic treatment of scrofulosis and tuberculosis is naturally very 
important. In scrofulosis especially attention must be devoted to diseases of 
the skin and mucous membrane,, since it is here that new germs constantly find 
ingress to the organism. In tuberculosis proper measures must be instituted 
in regard to expectoration, cough, hemoptysis, fever, vomiting and diarrhea. 

Very little is to be expected of the so-called specific general treatment. The 
preparations of iodin and iron may offer valuable aid in certain cases, especially 
in scrofula. Cod liver oil requires an intact gastro-intestinal tract. In erethis- 
mic scrofula where metabolism and excitement are increased, the graceful struc- 
ture and thin body require fat, and a methodic treatment with cod liver oil is 
in place. In the torpid form, with a flabby physique, constant digestive dis- 
turbances, retarded metabolism, and great repugnance to cod liver oil, nothing 
favorable can be accomplished with this remedy ; on the contrary, the excretion 
of the sour, offensive feces which contain volatile fatty acids, is increased, the 
nutrition still more involved and digestion ruined. Creasote I believe to be a 
very valuable remedy, perhaps the only one which has retained confidence in the 



PROPHYLAXIS AND TREATMENT 307 

treatment of tuberculosis. Given to small children, in water with aromatic 
tinctures, or with the addition of a few drops of ether, or in cod liver oil, to 
older children in gelatin capsules, it has produced excellent results in my hands. 
It should be instituted early and the dose should be gradually increased. Im- 
provement of appetite and of metabolism are the first noticeable results. Albu 
and Weyl observe that even after prolonged administration of creasote virulent 
tubercle bacilli may still exist in the sputum. This should not prevent our use 
of the drug; in many cases, after a positive improvement in nutrition and of 
the general condition, I have observed a conspicuous decrease of bacilli in the 
expectoration, and I believe that its action is principally a chemical immuniza- 
tion by destruction of the toxins. Creasotal and thiocol appear to exert a simi- 
lar effect. 1 

Tuberculin has been generally abandoned; it is of value for diagnostic pur- 
poses but it is not reliable nor without danger. Almost all authors, with the 
exception of Maragliano and Spengler, advise caution in its employment as a 
curative measure in tuberculosis, at least in childhood. 

Although at this time we have no specific for tuberculosis we must not 
abandon hope. Perhaps serum therapy will here also disclose new ways and 
means. However, we are not helpless, but have many protective measures at 
our command against the most destructive of all plagues. Our present way 
lies in prophylaxis, hygiene and dietetics. Here, proceeding .methodically, 
without weariness, we will slowly, very slowly, but nevertheless certainly, find 
the means to prevent this pest and to destroy the root of this poisonous growth. 

1 Creasote holds an uncertain percentage of guaiacol. That is why I have preferred 
for nearly twenty years (upon the recommendations of Schuller) the use of guaiacol, 
or (the more tasteless, but more expensive) guaiacol carbonate. I never treat a 
chronic case of tuberculosis without it. As a tissue builder I give small doses of ar- 
senic. I never omit giving a moderate dose of a cardiac stimulant when indicated. 
Small doses of digitalis may be given through months and years for that purpose. 
What I published on that subject 1884 (Trans. Med. So. St. New York) I have verified 
in thousands of cases since. There is no cumulation when thus used. As they have 
commenced to use digitalis in this way in Germany, in stray cases, for the same 
purpose and according to my rules, we Americans shall adopt the method. — Editor. 



HEREDITARY SYPHILIS 

By H. FINKELSTEIN, Berlin 

As the entire subject of syphilis will be discussed in another portion of this 
work by an authority x I will content myself with a retrospect of the enormous 
number of clinical phenomena with which we meet in medical practice as the 
consequence of heredity. 

The history of syphilitic families presents a scale of gradually decreasing 
effect upon the descendants. At first there are abortions ; in later years prema- 
ture labors. Then the period of pregnancy gradually approaches the normal, 
but the children are still-born, often a feet us sanguinolentus. Living children 
are next brought into the world, at first greatly diseased, in whom life is soon 
extinguished ; later more vigorous children are born who present the first con- 
sequences of a specific infection after some days. Finally, the power of hered- 
ity is exhausted and the children remain free of symptoms. 

Not infrequently there are exceptions to this ordinary course. Even when 
no artificial interference has been attempted through the beneficent influence 
of energetic treatment, sometimes a child is born, among others who are ex- 
tremely feeble or even dead, that is but slightly affected or perhaps perfectly 
healthy. It has occurred of twins that one was affected and the other was free 
of disease. Furthermore, recently infected parents may beget only healthy 
children. The hereditary transmission is therefore not obligatory, and many 
an experienced syphilographer believes that the importance, especially of sper- 
matic heredity, has for the most part been grossly exaggerated. 

Notwithstanding such deviations, our average experience may be general- 
ized by certain conclusions which approximately are laws : With the approach 
of the period of parental affection the deleterious importance increases for the 
offspring, i. e., the severity of infantile syphilis. Again : The more severe the 
disease in the child, the earlier in life are the symptoms unfolded. Therefore, 
fetal and severe syphilis, and extrauterine and mild syphilis, on the whole be- 
come parallel conceptions, and the second again is the more benign the longer 
the interval from the day of birth to its' appearance. 

There is also an anatomic foundation for the greater deleterious effect of 
fetal syphilis in the form of extensive changes of vital organs, which usually do 
not occur when the disease begins extrauterine but are substituted by symptoms 
on the part of the skin and mucous membranes. Much labor has been expended 

1 E. Lesser, " The Heredity of Syphilis." Volume on Dermatology. 

308 



FETAL SYPHILIS 309 

for an explanation of the varied localization of early and late hereditary syph- 
ilis. Thus, Hochsinger believes that the virus has a special affinity for glandu- 
lar organs and attacks them at a time when the greatest formative and nutri- 
tive stimulation exists in the region involved. In fetal life this aggression 
occurs in the internal organs; after birth in the skin, which is of vigorous 
growth. Nevertheless, late post-conceptional infection which takes place after 
the development of the internal organs is completed may be localized in the vis- 
cera (Finger), and eruptions are not unusual in the fetus. The central ner- 
vous system — not rarely involved during fetal life — is seldom attacked after 
birth, notwithstanding its enormous growth. Heubner's explanation is much 
simpler. He holds that an attenuated poison, although capable of adhering to 
the skin, cannot propagate where there is energetic circulation such as occurs 
in the internal organs. Therefore not the time but the severity of the infec- 
tion is the determinate factor. In severe, virulent syphilis the internal organs 
are always affected, immaterial whether the outbreak occurred in fetal life or 
a few weeks after birth. Proofs of the latter condition are numerous. That 
such cases are seldom observed arises from the fact that only the rare coin- 
cidence of recent, severe, untreated eruptions with fatal complications brings 
such children to the autopsy table. 

Therefore fetal syphilis is predominently visceral, not because it is fetal, 
but for the simple reason that only a severe infection can produce the disease 
in liter o; the syphilis of infancy runs essentially an external course because it 
is usually mild. When, exceptionally, the syphilis of this period is apparently 
severe, as is indicated by the intensity of the external symptoms, it is very 
probable that a visceral localization will also be found. 

Notwithstanding these indefinite boundaries it is convenient, for purposes 
of discussion, to divide the affection into fetal syphilis and syphilis of infants. 



I. FETAL SYPHILIS 

The factor which raises a suspicion of syphilis in the fetus is the intra-uter- 
ine death with abortion or premature labor, especially if repeated and other 
sufficient causes are not apparent. This suspicion can be confirmed only by 
an examination of the internal organs, except in those cases where there is 
pemphigus, which at once removes all doubt. 

Histologic changes do not occur earlier than the beginning of the fifth 
month, and the cause of death of the embryo before that period must be sought 
elsewhere; either it is due to the severity of the general intoxication which 
destroys the delicate germ, or disease of the placenta gives rise, through changes 
in the vessels, proliferative granulations, gummata, induration and contraction 
in the villi, to destruction and constriction of the blood lacunas and retarded 
metabolism, the result being the death of the fetus. 

Definite changes in the organs may be demonstrated from the fifth month. 

The recognition of these changes frequently presents no difficulty, espe- 



310 HEREDITARY SYPHILIS 

cially when they appear in various regions as large gummata or gummatous 
infiltrations. In the overwhelming majority of cases, however, the macroscopic 
signs are less obvious and are limited to a change in the color and condition of 
the blood, and to an increase of volume and consistence of the affected parts, 
the specific foundation of which is only revealed by the microscope. 

Enlargement of the spleen and the frequent volumetric increase of the 
liver are of diagnostic significance, and in proportion to the weight of the 
child are very decided (liver 1: 14.7, spleen 1: 198; in contrast with 1:21.5 
and 1 : 325 respectively of the normal. All uncertainty will at once be re- 
moved by an incision through the epiphysis Of a tubular bone to determine the 
presence or absence of the osteochondritis of Wegner, which is an almost con- 
stant pathognomonic sign of the disease. 

The essential feature of fetal syphilis is the specific disturbance of endo- 
chondral ossification. The calcification of cartilage continues undisturbed, but 
resorption is prolonged and change into bone does not occur. The proliferating 
osteogenic tissue between the column cells of the cartilage is denuded of osteo- 
blasts and resembles a simple granulation tissue. This explains the macro- 
scopic appearance of the cartilagino-osseous border: distribution of the whitish, 
mortar-like zone of provisional calcification, serrated limitation in consequence 
of prolonged existence of the calcified column cells and irregularities in the 
prominence of the granulation tissue, sclerosis and friability of the entire bone, 
because everywhere the deposits of calcium are loosened incompletely. In 
later stages, under the influence of the specific damage, there may be fatty 
degeneration, liquefaction and necrosis, and, finally, solution of the feebly elas- 
tic calcium structure of the cartilaginous epiphysis. 

Further diagnostic criteria are furnished by microscopic examination of tli e 
internal organs, particularly the kidney, spleen, thymus gland (Hecker). 

The changes peculiar to hereditary syphilis may in general be defined as 
small-cell infiltration, associated with proliferative phenomena in the con- 
nective tissue, which is focal or distributed diffusely over entire organs or por- 
tions of organs, and possesses a conspicuous tendency to indurate. Typical vas- 
cular disease is also observed. 

The individual components of this process are: 1. Multiple circumscribed 
cell accumulations, as well as intraparenchymatous, interstitial, and perivascu- 
lar, which may attain a macroscopic prominence (miliary syphilomata) and 
lead to gummatous processes when, especially localized around the larger ves- 
sels. They are pathognomonic of syphilis. 2. Diffuse and circumscribed con- 
nective-tissue proliferation, which may increase to the point of induration and 
cirrhosis, undoubtedly is also of great diagnostic importance. 

3 and 4. The diffuse, small-cell infiltration and peculiar epithelial struc- 
ture which are found in the lungs, kidneys, and thymus, are more difficult to 
estimate. The diffuse, small-cell infiltration often permeates the tissue to 
such an extent that at first glance the structure is not recognizable. Its spe- 
cific importance has recently been questioned, and Hecker, Terrier and Karvo- 
nen in particular have emphasized the fact that even under normal conditions 



FETAL SYPHILIS 311 

the fetal organs, notably the liver, may contain a diffuse accumulation of cells 
and thus cause confusion. It is likely that this variety of microscopic pictures 
does not present, wholly at least, a specific inflammatory proliferation but is 
only a fetal phenomenon, perhaps of a somewhat longer existence under the in- 
fluence of syphilis, but otherwise normal. 

Epithelial structures, in the form of focal accumulations of cylindrical or 
cubic epithelial cells or persistent cylinders, are found in the lungs as the 
remains of fetal pulmonary tissue. In the kidney there is a subcapsular neo- 
genic zone in which the canal system also remains in a fetal condition, without 
separation into Bowman's capsule, convoluted tubules, etc. Hassal's thymus 
bodies will be mentioned later. The explanation which has been given for 
these conditions is that they are the remains of an abnormal separation of 
portions of glands which has arisen from a syphilitic inhibition of growth. 
Hochsinger believes them to be due to the local damaging effect of the specific 
proliferation; Karvonen ascribes them to the general effect of toxins. 

Karvonen's theory endeavors to unite all of these points of view. It con- 
trasts a syphilo-toxic influence, which inhibits development and causes diffuse 
cellular proliferation and persistent epithelial formation, with circumscribed 
specific proliferation. The inhibitive influence is shown by the persistence of 
the tissue in the fetal condition : The milder grades of perivascular infiltration 
are only normal vessels about to be formed; the diffuse cellular infiltration is 
in fact a mesenchyma which remains in an embryonal state, and the epithelial 
structures are to be considered likewise. This, then, is the basis upon which 
the typical focal proliferations develop. Although certain authorities (Hecker) 
have contradicted some of these points it cannot be denied that the theory 
has much to commend it. In favor of an existing influence which inhibits 
development is the generally protracted growth of the syphilitic fetus and 
primarily the process, above described, in the epiphysis of the bones. The 
theory of Karvonen combines many of these well known facts under a gen- 
eral law. 

In regard to the individual organs, the infiltration and the newly formed 
connective tissue along the portal capillaries permeate the liver between the 
trabecular and in the further course may lead to diffuse sclerosis. The capsule 
is often decidedly thickened. Miliary syphilomata are common; rarely there 
are larger nodules and gummatous inflammation around the porta which may 
originate from the biliary passages as well as from the trunk of the portal vein 
(peripylephlebitis, Schuppel). 

The pancreas is a selective area of infiltration and induration. Eecent in- 
vestigators believe that the kidneys also are constantly involved, especially by 
cellular infiltration around the smallest cortical vessels. 

Indurative enlargement of the spleen, as an important and almost pathogno- 
monic symptom, has already been mentioned. 

In the lungs, apart from large or smaller gummatous nodules, " white 
pneumonia " is to be found : blocking of the alveoli and bronchi with fatty 
degenerated round and epithelial cells, with unchanged interstitia. Interstitial 



312 HEREDITARY SYPHILIS 

(diffuse infiltrative) pneumonia is more frequent and is commonly associated 
with white inflammation which in pure condition is extraordinarily rare. 

The thymus gland, which in addition to diffuse infiltration may contain 
nodules, occasionally reveals the rare finding of cystic spaces filled with puru- 
lent masses (Dubois's disease). This condition is due to an inhibition of invo- 
lution, in that the remains of the epithelial tubules which form the first founda- 
tion of the gland (HassaPs bodies) do not disappear but become distended and 
enlarged by the entrance of thymus substance or of thymus cells which after- 
ward undergo fatty degeneration. 

Eelatively frequent characteristic changes have been found in the central 
nervous system, especially in recent years ( Jiirgens, Matthewson, Gasne, Gilles 
de la Tourette). Other organs which have not been especially mentioned may 
also be the occasional seat of pathologic products. 

Vascular proliferation and perivascular infiltration are occasionally ob- 
served in the umbilical cord and may sometimes be of diagnostic value when 
autopsy is impossible. 

It is obvious that more decided grades of the visceral changes which have 
been described are not compatible with life. Therefore the frequency of still- 
births in the anamnesis is important in connection with the next category, the 
main factor of which is the " polymortality " (habitual mortality) in syphilitic 
families. It is true, other children may be born alive but prematurely, as 
wizened and sickly subjects. Significant of these syphilitic premature births 
is the retardation in weight and bodily development, in contrast with normal 
children carried the same length of time, and a " defective vitality " which can- 
not be combated by the most careful nursing and which is manifested by a non- 
resistance to even secondary infections. Many die after hours or days ; only a 
small minority live more than a week. 

The last group is of greatest interest to the physician. These children 
also, carried to full term, but born with the florid symptoms of the disease, 
must be regarded as fetal syphilitics. 

Here also are found a shortage in weight, sometimes amounting to actual 
atrophy, and the " defective vitality " which permit the assumption of severe 
internal localization. Among the occasional recognizable external signs is 
rhinitis, which later becomes so important, and exceptionally a bullous exan- 
them — pemphigus syphiliticus — is observed. 

The exanthem is first distributed in the form of scales over the entire 
body, soon followed by the formation of a serous fluid, afterwards purulent, 
resembling vesicles, which raises the epidermis. An important factor in the 
differentiation from pemphigus neonatorum is the localization upon the palm 
of the hand and sole of the foot, for here the largest vesicles are situated, some- 
times of the size of a cherry. Extensive and severe cutaneous affections may 
arise by coalescence, formation of fissures, and ulceration. 

The prognosis of these cases is bad, 1 not so much because of the peculiarity 

1 In regard to the necessary strict differentiation from a pustulous syphilide, see 
later. 



SYPHILIS OF NURSLINGS 313 

of the eruption, although it resembles syphilis maligna in its resistance to spe- 
cific remedies, but on account of the serious internal complications. Only the 
greatest care will prevent secondary septic infection. 



II. SYPHILIS OF NURSLINGS 

A. SYPHILIS OF THE SKIN AND MUCOUS MEMBRANES OF THE FIRST 

ERUPTIVE PERIOD 

A child, apparently normal, is born and for a time a slumbering affection 
is unsuspected, until the appearance, often surprising, of unquestioned symp- 
toms reveals the true state of affairs. This period of latency may be measured 
by days, weeks, or months. Among 344 children Eosen saw the infection 
appear in the first month 157 times, in the second month 111 times, in the 
third month 42 times, and much later in 31 cases. In 46 of my patients the 
earliest appearance of the exanthem was as follows : between the first and third 
days 4 cases, end of the first week 5, second week 4, third week 5, fourth week 9, 
fifth week 5, sixth week 3, seventh week 7, and 1 case each in the eighth, tenth, 
and thirteenth weeks and fourth month. No trustworthy reports can be ob- 
tained of the beginning of the eoryza which for some time precedes this con- 
dition. 

The existence of such an " incubation " period is of the greatest practical 
importance. The suggestion is sufficient of the serious conditions which may 
be produced if a child, who has been given to a wet-nurse, subsequently becomes 
ill, or if, after some weeks, the child of a wet-nurse develops syphilis. Direc- 
tors of foundling and orphan asylums must at all times bear in mind that an 
apparently healthy child may be the source of contagion to its adopted parents. 

Therefore the earliest possible diagnosis, the recognition and scrupulous 
observation of the first symptoms of the disease, are essential. The secondary 
period of hereditary syphilis begins with an exanthem only in the minority of 
cases, just as in an acquired syphilis. As a rule there are insignificant ante- 
cedent phenomena, often for a long time previously, which at least arouse sus- 
picion and frequently give to the experienced physician positive proof of the 
existence of the disease. Their consideration is all the more urgent since trans- 
mission to those about the patient is possible from these early phenomena. 

Primary among these symptoms, and one which is seldom absent, is snuf- 
fling, at first dry, later accompanied by mucous rales — a sound during nasal 
respiration which is particularly distinct when the mouth is closed. The 
underlying cause is eoryza syphilitica, which begins with dry swelling, suc- 
ceeded by a tenacious, crust-like secretion, and finally shows a profuse purulent 
and hemorrhagic discharge, probably due to secondary bacterial accumulation, 
with simultaneous infiltration, fissures and ulceration upon the alse of the nose. 
If the nasal passages are entirely blocked there is a conspicuous position, par- 
ticularly of the neck, which resembles opisthotonos and probably facilitates 



314 HEREDITARY SYPHILIS 

the introduction of air. With an intense and prolonged coryza the pathologic 
processes exceed the limit of the mucous membrane and lead to changes which 
may also affect the external appearance of the nose. In mild cases the change 
is limited to a cicatricial retraction resembling pug-nose, and an occasional con- 
traction which may occlude the nasal passages almost to the extent of imper- 
meability. Involvement of the cartilaginous and osseous structures (inflamma- 
tory nutritive disturbances, rarefaction or softening in the growing cartilage 
and bone) results in a sinking of the bridge of the nose (saddle-nose). Ulcers, 
perforations of the septum, and gummatous destruction of bone are excep- 
tional occurrences. Perforation of the hard palate has been reported. 

The " micropolyadenia " (multitude of small glands) of acquired syphilis 
is usually absent, and is of no diagnostic value should it occur. Even the 
enlargement of the cubital glands, which some authors declare to be important, 
in my experience is significant only in combination with other suspicious symp- 
toms and when the glands are prominent (the size of a pea or larger). Other- 
wise slight enlargement is common. On the other hand I have not thus far 
found a chain of palpable glands along the sulcus bicipitalis elsewhere than in 
syphilis, although only in older infants. The splenic enlargement can be 
utilized in diagnosis only in conjunction with other phenomena. 

Among 52 children I found a palpable spleen in 39 cases (75 per cent.) ; 
of these 4 attained the size of a decided tumor. The importance of this finding 
is lessened by the fact that at this period particularly a slight enlargement of 
the spleen can. be demonstrated in many non-syphilitics. 

More typical are the cutaneous changes, especially in the face. Here we do 
not search for pallor — which has often been designated as characteristic, but 
which I have frequently not found — but for certain peculiar phenomena of in- 
filtration which, as a rule, soon follow the coryza. Around the border of the 
lips a reddish yellow, glistening zone appears, several millimeters broad and 
somewhat coarse, which is soon deeply fissured and may even implicate the red 
of the lips. The condition around the ala nasi has already been mentioned. 
Even the region of the eyebrows is coarse, thickened, and slightly desquamated. 
In addition the face presents a brownish yellow or pale yellow color— as of 
"cafe au lait or of the fingers of a cigarette smoker" (Trousseau) — which 
assumes a red tint around the chin and is simply a milder form of the same 
infiltration. Similar changes may appear around the anus, genitalia, and the 
flexor surface of the thighs. At this time alopecia — scant hair upon the head, 
brows, and eyelids — becomes conspicuous. To summarize: the complexion, 
lymphatic enlargement, alopecia, coryza, snuffling, and the nasal quality of the 
voice present in typical cases an unmistakable picture, which, however, is read- 
ily recognized by experts in a less marked or rudimentary form. 

Other symptoms referable to the skin need not necessarily appear in addi- 
tion to the changes already mentioned. Nevertheless, with a typical course, 
cutaneous eruptions are to be expected in the form of diffuse or circumscribed 
exanthemata. 

The diffuse exanthemata are localized preferably in the regions, already 



SYPHILIS OF NURSLINGS 315 

mentioned, of the cutaneous changes and infiltration, and may be regarded as 
an exaggerated form of the same conditions. The swelling becomes more dis- 
tinct and extensive, the color a brownish red, and the desquamation more 
marked, especially around the nose and mouth where the tense borders are per- 
meated by radial fissures, and upon the ears, the forehead and the hairy scalp. 
The desquamation may increase to a true seborrhea which covers the surface 
with a scaly rupial or eczematous crust. 

This " diffuse infiltration/' as it is designated by Hochsinger, is said by 
him to involve extensive areas, especially the posterior surface of the lower 
half of the body from the sacrum to the heels, the anterior surface remaining 
exempt. Complications with macerating processes then produce an extensive 
intertrigo which corresponds in its location to " the leather patch of riding 
breeches." The specific importance of this form of eruption is probably not 
applicable to all cases. 

The same infiltration appears on the soles of the feet either in the form of 
swelling of the skin, which becomes coarse and glistening, with folds and scales 
and of a light brownish yellow color, or as a scaty, bluish red erythema resem- 
bling lacquer. The palm of the hand presents the same appearance. The ordi- 
nary reddening of the planta, observed in atrophic children, is to be differen- 
tiated from that of a syphilitic affection by the thickness of the skin. 

Diffuse exanthemata are a frequent but by no means constant phenomenon 
of the disease. Like the milder cutaneous infiltrations, they may be absent. 
Cases sometimes occur without the appearance of rhinitis, the development then 
being sudden, with an eruption, corresponding to its onset in adults. I have 
particularly noted the absence of all prodromal symptoms in cases where rea- 
sons on the part of the parents made a careful observation of the newborn 
imperative. 

The characteristic circumscribed exanthemata develop either upon and be- 
tween the diffusely affected areas or as primary cutaneous eruptions. Their 
appearance may be ushered in by fever, likewise as in adults. They require 
no comprehensive description ; it is sufficient to call attention to the conformity 
with the picture of later life, to which but a few remarks need be added re- 
garding special conditions. 

True to the experience that the severity of infantile syphilis constantly 
diminishes with time, here also the forms which arise early are the more grave. 
Actual primary ulcerous exanthemata appear to be absent. 

Thus, the pustulous syphilide only appears at the onset, seldom after the 
third week. The large pustules abound on the palm of the hand and sole of the 
foot, as in congenital pemphigus, which is in fact a more severe type. The 
unfavorable prognosis of congenital pemphigus, however, does not apply to the 
pustulous form — all of my cases were cured, and the diversity of opinion of 
various authors regarding the prognosis of pemphigus is probably due to the 
less distinct differentiation from the pustulous syphilide after the first or 
second day. According to my experience only those cases are serious in which 
not only the palmar and plantar surfaces and their surroundings are involved 



316 HEREDITARY SYPHILIS 

but actual vesicles appear over the entire body. Papulo-pustulous efflorescences 
are significant of a more favorable condition. 

The exanthemata, of longer incubation are the macular, papular, and more 
or less squamous forms, and those resembling roseola. They may appear in 
profuse crops like measles, or as a few faint efflorescences. Larger plaques may 
develop by confluence. The preferred and characteristic localizations are on 
the palms and soles, where the desquamating forms, known as psoriasis pal- 
maris and psoriasis plantaris, predominate. Scaly and often round infiltrates 
are found upon the fingers and toes; paronychia and trophic changes in the 
nails are common. 

It appears worthy of remark that mucous membrane plaques and condy- 
lomata occur in the nursling during the first period of eruption — I have seen 
them upon the tongue, lips, pharynx, and genitalia — but they play no promi- 
nent role. In fact an implication of other mucous membranes than that of the 
nose is quite uncommon. Perhaps the most frequent involvement of the 
mucosa is in the larynx. Disease of this organ is characterized by decided 
hoarseness which may exceptionally increase to aphonia. The anatomical basis 
is probably the same as that of coryza. At the autopsy of one of my cases in 
which the aphonia had existed from birth the vocal cords were found covered 
with massive fimbriated papillomata ; no other specific laryngeal changes were 
observed. In this early period severe and even fatal disturbances occasionally 
occur ; stenosis with ulcerations and perichondritis, requiring tracheotomy, have 
been reported. A careful analysis of most of these cases, however, raises the 
suspicion that there were complications with diphtheria or sepsis. 

B. SYPHILIS OF THE BONES AND INTERNAL ORGANS IN THE FIRST 
PERIOD OF ERUPTION 

In the minority of syphilitic infants there is an implication of the same 
organs which are commonly attacked in utero. These visceral forms may be 
classified under two groups : first, that form in which beginning changes do not 
necessarily lead to death of the fetus, but continue for some time after birth 
("projection of fetal syphilis"); second, those cases in which the internal 
organs present disease simultaneously with severe cutaneous syphilitic erup- 
tions. 

Eelatively the most frequent are disease of the bones. Aside from the 
gummatous thickenings upon the internal and external surface of the flat bones 
of the skull, and the multiple phalangitis upon the fingers and toes which re- 
sembles spina ventosa, we are most interested in the condition of the long tabu- 
lar bones. 

Wegner's osteochondritis, which is of sufficient frequence in the nursling 
to maintain an anatomico-diagnostic importance at the autopsy, is not clinically 
recognizable in the mild and medium stages, except perhaps by the Kontgen 
rays (Holzknecht). Only when the inflammatory process attacks the perios- 
teum are external changes demonstrable in the form of spindle-shaped protu- 
berances limited to the epiphyseal regions, the anatomical foundation of which, 



SYPHILIS OF NURSLINGS 317 

in the severer grades of the epiphyseal affection, is a many-layered thickening 
of the periosteum with a gelatinous or caseous infiltration. Such an enlarge- 
ment may be found unilaterally or bilaterally upon all of the long bones, but 
seldom upon the trunk. The upper extremity is involved to a greater extent 
than the lower, therefore the affection can be best studied in the arms. 

Here the thickening occurs near the elbow and frequently upon the distal 
epiphysis of the lower arm. The upper humeral epiphysis is rarely involved 
to a perceptible extent. While the joints are yet intact there is frequently a 
swelling of the soft parts and a manifestation of pain upon contact or passive 
movement. The most remarkable, though not obligatory, accompanying phe- 
nomena are peculiar disturbances of movement, which, following the example 
of Parrot, have been designated " pseudo-paralyses" and produce the following 
clinical pictures: 

One arm or both are extended in flaccid paralysis and rotated inward with 
the pronated hand alongside the trunk. The position has a surprising resem- 
blance to complete plexus paralysis. The hand when raised, has a pendulous 
motion with the position of radial paralysis. Movement is possible only in the 
fingers, although a tendency to muscle action is occasionally observed in other 
regions, notably the adductors. 

The paralysis is not always so complete. Sometimes there is only a diffi- 
culty of movement. I have also noted a clinical picture which resembled 
paralysis of a peripheral nerve rather than of the plexus ; for instance, in one 
case, a typical radial paralysis, in another a left-sided claw position and failure 
of all movements dependent upon the ulnar nerve. 

The pathogenesis of this motor disturbance has not been satisfactorily 
solved. Some of the attempted explanations — and particularly that of Par- 
rot — make it dependent upon disease of the bone. This leads to solution of the 
epiphysis, and the result thereof and of the pain on movement is a reflex posi- 
tion of rest. But in many of the cases the loosening, which is demonstrated by 
crepitation and abnormal movability, is not present. 

Oberwarth maintains that the slightest change in the epiphysis produces a 
periosteal irritation whereby every contraction of the muscle causes pain and 
discomfort and for this reason there is naccidity. By a similar train of thought 
Hochsinger assumes a specific disease of the muscular insertion on the bone. 

These explanations may suffice for a number of cases, but not all, particu- 
larly when there is complete absence of pain upon passive movement and pres- 
sure, as is not infrequent. Further, there is by no means a direct parallelism 
between the osseous process and the disturbance in function. In cases of equal 
enlargement on both sides Henoch, as well as I, have noted only a unilateral 
motor disturbance. The rapid return of function under treatment, even before 
a visible influence on the bone, is likewise in evidence. 

Accordingly, mention must be made of those views which refer the condi- 
tion to disease of the nerves. Affection of the peripheral neuron, through the 
irritation of gummatous bony enlargements on the arm or in the intervertebral 
spaces (Keuter), is unlikely, as such a condition could scarcely occur without 



318 HEREDITARY SYPHILIS 

marked sensory irritative phenomena, which are not clinically apparent. Men- 
ingeal or central processes, however, may be operative. In these cases a closer 
observation of the pathologic findings is necessary. 

The purely nervous foundation cannot be rejected when there is paralysis 
without a clinically demonstrable affection of the bones. 

The knowledge of this particular form of syphilitic paralysis is not exten- 
sive, nevertheless it is of great importance, as errors in diagnosis may lead to 
therapeutic sins of omission. Diagnostic confusion occurs all the more readily 
because the condition may be congenital, resembling obstetric paralysis, or, if 
the paralysis occurs after birth, often quite acutely, it has an apoplectiform 
appearance. Furthermore, this type of syphilitic paralysis is rarely accom- 
panied by eruptive phenomena. Much more frequently one condition succeeds 
the other, or eruptions are altogether absent and only visceral complications in- 
dicate the etiology. For an understanding of this peculiarity the same remarks 
are applicable which will be found in the later discussion of syphilis of the 
liver. 

Clinically these paralyses throughout follow the type of obstetrical paraly- 
sis. The most common form is complete lower plexus paralysis ; paralysis of one 
upper extremity is unusual. The oculo-pupillary phenomena of Klumpke's 
paralysis (myosis, contraction of the palpebral fissure) may be present. 

Two proofs are known at this time which favor the view held by Peters of 
a central origin of these paralyses. Zappert found meningitis in the cervical 
cord with columnar degeneration ; in a case characterized by bilateral paralysis 
of the arm, paralysis of the sphincter, and flexor contracture of the leg, I 
found recent, partly diffuse, partly nodular, gummatous infiltrations of the 
entire central nervous system with here and there a well-developed sclerosis. 

At this point must be mentioned the contractures of syphilis which occur 
alone or as the accompaniment of .paralysis of the muscles of the neck, of the 
iliopsoas, of the flexors of the arms, etc., and which disappear under specific 
treatment. They are little understood and it is difficult to determine in how 
far specific diseases of the nervous system, perhaps also of the muscles, and' 
further the non-specific permanent contractures which are so pronounced in 
very sick children, deserve etiologic consideration. 

In the legs the same osseous changes and flaccid paralyses occur as are 
found in the arms, though the paralysis is much less frequent. 

Implication of the central nervous system, as has already been mentioned, 
is not unusual in fetal life. It appears, however, that florid stages of infiltra- 
tion, sclerosis, meningitis, and vascular disease, originating at this period, as 
occurred in my case just quoted, are rarely consistent with prolonged extra 
uterine existence. Nevertheless, it is likely that in the stage of cicatrization 
they give rise in a certain percentage of cases to Little's disease and other forms 
of infantile cerebral paralysis, as well as to congenital idiocy and epilepsy. 

Congenital hydrocephalus also is frequently associated with syphilitic 
heredity, even such forms as are not influenced by specific treatment. In these 
cases the relation to syphilis resembles that in tabes dorsalis. Indications of 



SYPHILIS OF NURSLINGS 319 

hydrocephalus (prominence of the fontanelles, downward glance), as Oedman- 
son rightly emphasizes, are common. Brit there is also quite a series of re- 
ported observations of well-marked cases which have been cured by an energetic 
administration of iodin and mercury ; probably in these patients there was not 
an ordinary hydrocephalus but a specific meningitis with marked exudation or 
ivith occlusion of the ventricles, as has been described by Astros, Haushalter 
and Thiry, and was observed also in a case of my own. 

In addition to that form of meningitis distinguished by ventricular effu- 
sion there is also a very characteristic gummatous basilar meningitis (Growers, 
Hadden, Oppenheim) with special implication of the posterior cranial fossa, 
or occasionally, as in one of my cases, with involvement of the middle groove 
and defined by various symptoms on the part of the basal nerves. Syphilomata 
and endarteritis appear to belong only to the period of relapse. 

Disease of the eyes may to a certain extent be regarded as a continuation of 
the cerebral affection. Among the most prominent findings is that of gray 
(post-neuritic?) atrophy, which runs its course without other concomitant 
nervous phenomena and is only discovered by special investigation in that 
direction (Kalischer). The fate of such cases is unknown. Choroiditis is 
apparently more common in later months. Keratitis parenchymatosa of the 
external eye is rarely observed in after life. Primary plastic iritis is pathogno- 
monic and may develop in utero — I myself have found an extensive posterior 
congenital synechia in the newborn. 

Syphilis of the liver in the form of tumescent hepatic gummata is of very 
exceptional occurrence in the nursling. More common is a diffuse affection 
which is rare in the adult. This is observed either as a recent infiltration pro- 
ceeding from the capillaries of the portal vein, which results in a portal hyper- 
plastic cirrhosis, or as the biliary, icteroid form, which is produced by changes 
in the bile-channel system. 

Recent diffuse hepatitis as a complication of external eruptions is to be 
expected with greater likelihood the more the intensity of the external symp- 
toms favors the severity of the individual case. This condition can be estab- 
lished with certainty if, in addition to other syphilitic phenomena, an enlarge- 
ment and especially a positive hardening of the organ can be demonstrated by 
palpation. There is also splenic tumor. Jaundice and ascites are absent. 

A positive diagnosis in those cases which have not yet reached the stage 
of sclerosis, and therewith an opinion in regard to the frequency of such cases 
in the living, is subject to many clinical and anatomical uncertainties. 

Even the demonstration of an enlargement is not simple, except in extreme 
cases. Quite frequently in the normal infant the liver is palpated in the mam- 
millary line about 3 cm. below the arch of the ribs ; therefore only greater devia- 
tions than this are of diagnostic importance. Within this limit, among 40 
syphilitics I found hepatic enlargement in only 5 cases (12.5 per cent.) — 
greater than Kraus's figures (1.8 per cent.), but much less than Hochsinger's 
(31 per cent.). Furthermore, enlargement of the organ may not occur even 
in a severe affection. 



320 HEREDITARY SYPHILIS 

In the absence of other symptoms, to consider the enlargement as a mani- 
festation of specific hepatitis is not justifiable. There may be fatty liver, stasis, 
and other conditions. The result of anatomical investigation must also be 
utilized with caution. In addition to the delusive possibilities already men- 
tioned, i. e., the relation of fetal conditions to those of life, there are disturb- 
ances such as gastro-enteritis, sepsis and other fatal complications, which may 
cause an interstitial accumulation of cells. We may assume with some 
certainty the diffuse infiltrating form of hepatic syphilis when we can demon- 
strate clinically a distinct increase in consistence. 

When the disease of the liver has reached its acme in fetal life the child is 
born with an organ which is already in the stage of induration — with complete 
cirrhosis — and usually in a hyperplastic condition ; exceptionally there is begin- 
ning contraction. Such patients are extraordinarily pale and cachectic, with 
distended abdomen over which the veins are plainly visible, often with dropsi- 
cal symptoms, and above all with a conspicuously hard liver, usually still en- 
larged, as well as a coarse splenic tumor. As a rule there is a large amount of 
indican in the urine. Jaundice is absent in these cases; in a few instances 
ascites has been observed. Secondary symptoms of the disease are seldom noted. 

This absence of exanthemata or of rhinitis does not justify a doubt of the 
specific nature of the cirrhosis. Anyone who questions it has forgotten that in 
these cases the period of eruption, and with it the time at which external mani- 
festations are to be expected, was passed in the uterus, that traces may remain 
of a profound hepatitis in the form of induration, but not of a transitory and 
insignificant cutaneous affection. Theoretically we must expect only such 
changes as are equivalent to the hepatic affection; if cutaneous symptoms 
appear, as in a case of Henoch's, these must be explained as a relapse. Twice 
among 4 cases I have seen osteochondritis as an accompaniment, in one case in- 
duration of the testicles, and in the remaining case an isolated, severe, large 
lamellar psoriasis plantaris et palmaris appeared, as might be expected, weeks 
after the congenital hepatic tumor had been determined. The absence of simul- 
taneous syphilides on the skin and mucous membrane is therefore no reason to 
reject the specific nature of the affection ; instead it must be expected. 

That cirrhosis is not observed more frequently and is only rarely combined 
with ascites is probably due to the fact that such severe changes seldom permit 
of a prolonged extra-uterine existence, and the few who survive these changes 
perish while there is yet compensation for the circulatory disturbance. In the 
infant there is an especial tendency to compensatory hypertrophy. 

Enlargement due to simple diffuse infiltrations appears to respond readily 
to therapeutic measures. More tenacious, and therefore obviously of less fa- 
vorable prognosis is the second category, although such cases are occasionally 
amenable to early and prolonged treatment. A case of Depasse's which was asso- 
ciated with ascites and several times required paracentesis, showed improv- 
ment in the course of two years ; nevertheless a certain degree of enlargement 
and hardening persisted. 

The second group — icteroid cirrhosis — includes a series of occurrences, 



SYPHILIS OF NURSLINGS 321 

also rare, in which — usually directly connected with icterus neonatorum, more 
rarely separated from it by a certain interval of time — high -graded icterus 
develops, sooner or later associated with acholic feces. The liver is large and 
hard : there is splenic tumor. In pure cases ascites is absent. If the cases are 
grouped into a common picture the result is an occlusion of bile from the in- 
testine which is complete at birth or has gradually developed in the first months 
after birth, and is associated with cirrhosis of the hepatic tissue. It is remark- 
able that in children who suffer to such an extent other symptoms of syphilis 
are not present or are at most merely suspected. The condition has frequently 
been observed in several children of the same parents. 

The changes, the end product of which has just been described, pass their 
florid stage in utero, the same as portal cirrhosis. Chiari and Beck have found 
in still-born children and in those who have lived for a few weeks a gumma- 
tous inflammation of the large biliary passages which permeated the liver tis- 
sue, and in the process of new connective tissue formation and indurative con- 
traction, necessarily led to changes in the form of obliteration of the biliary 
passages, cicatricial constricting proliferation, diffuse biliary (cholangitic) 
cirrhosis, and the effects of biliary stasis. At the autopsies of children who 
have succumbed after several months the anatomical picture shows the termi- 
nation of these processes distinctly (indurative changes at the porta, oblitera- 
tion to total disappearance of the biliary passages, cholangitic cirrhosis), while 
those cases in which bile is retained in the feces have not yet reached this stage. 

Schiippel has described cases with icterus, acholic feces, and ascites in the 
fetus and in still-born children and their cause — in contrast to cholangitis in 
the preceding cases — he has recognized as a peripyle phlebitis : a fibro-caseous 
inflammation starting from the main trunk of the portal vein which produces 
constriction and obliteration and in its further course may involve the biliary 
passages. Clinically, in addition to the principal symptoms, already mentioned, 
there was enlargement of the spleen and congestive hemorrhage from the intes- 
tines. In older children such conditions have not been observed. However, 
it is an important fact that at autopsies of older children we occasionally find 
deposits of circumscribed connective tissue which lead to peritonitis at the porta 
hepatis, and it is possible that by the formation of adhesions they may produce 
severe disturbances. 

Whether the cases of icteroid cirrhosis without ascites may be due to an 
inflammation principally affecting the large biliary channels is not yet clear. 
Some authors designate their findings simply as biliary cirrhosis, but nothing 
precise as to the condition of the porta can be gained from the reports. 

If we properly understand the anatomical basis of these occurrences the 
generally unfavorable prognosis is obvious. The appearance of the icterus is 
not the signal of the beginning of the disease itself but of the beginning of the 
end, — the obliteration of the biliary passages. 

The only benefit of specific treatment is to aid the natural tendency of 
cicatricial contraction. For the restitution without functional disturbance, 
which can be attained only very early, the favorable time for such treatment is 
22 



322 HEREDITARY SYPHILIS 

usually past. This early period coincides, perhaps with rare exceptions, with 
fetal life. As a rule the end succeeds about three months' duration of the 
jaundice. 

A differentiation of icteroid, syphilitic, hepatic cirrhosis from congenital 
agenesia, and from occlusion of the large biliary channels due to other causes, 
is only possible clinically when other evidences of syphilis are at hand or when, 
at least, it can be determined that the acholic discharges have appeared shortly 
after birth. Whether there is an accidental complication of syphilis with one 
of the non-specific varieties of jaundice must also be considered. However, in 
the latter case the liver would scarcely have a similar greatly increased con- 
sistence. 

Hochsinger doubts the syphilitic basis of the jaundiced cases because of the 
continual absence of other simultaneous specific phenomena, but that they are 
not always absent is shown by one of my cases (icteroid cirrhosis with a papulo- 
syphilide). Attention must also be called to what has been mentioned in the 
description of portal cirrhosis. 

Albumin and casts in the urine of syphilitic children is a very frequent 
happening, but it by no means justifies the conclusion that there is a specific 
affection of the kidneys. The same condition also occurs in non-syphilitics 
and in either instance is due to the action of complicating intestinal catarrhs 
and other ailments. According to numerous observations the urine of syphi- 
litics who are otherwise well is always free of albumin. The interstitial 
changes which occur in the kidneys of children who survive (Hochsinger, 
Hecker, Schlossmann, Karvonen) are not susceptible of diagnosis. On the 
other hand, it is not unlikely that there is an actual hemorrhagic nephritis 
with blood, casts, and a large amount of albumin in the urine, and with dropsy, 
as in the well-known condition of adults. Here, as there, the timely coinci- 
dence with other manifestations of the disease, the peculiar richness of fat 
granules in the sediment, and the uninterrupted recovery after mercurial 
medication, favor such a view. This form of hemorrhagic nephritis has been 
described several times. Many of the cases, however, might be attributed to 
mercurial intoxication rather than to syphilis. Only a few reports of Bradley 
and Oedmanson, and a case of my own in which neither the mother, during her 
pregnancy, nor the child was treated, appear to be positive in this respect. 

At several autopsies I have observed an extraordinarily extensive intersti- 
tial nephritis. It can be scarcely otherwise than that such cases undergo con- 
traction in later life, and by careful clinical and anatomical observation we may 
expect to find syphilitically contracted kidneys during the first years more 
frequently than has been reported heretofore (Hellendal, Massolongho). 

Occasionally a post-mortem examination shows that other organs have 
been attacked without causing any significant symptoms during life. Clinical 
interest is accordingly slight. Pulmonary syphilis is very rare in living chil- 
dren and the few cases soon succumb. The pneumonia which is so prevalent 
in syphilitics is probably always due to secondary infection. 

The occasional infiltrations, vascular affections and ulcerations in the 



SYPHILIS OF NURSLINGS 323 

stomach and intestine are not susceptible of a positive clinical diagnosis. The 
enlargement of the spleen is usually due to simple hyperplasia, exceptionally 
to a specific disease. 

The literature contains few reports relative to changes in the peritoneum. 
It has been mentioned above that specific peritoneal deposits occur at the porta 
hepatis; another point of preference is the capsule of the spleen. Occasionally 
the path of the perisplenic induration may be directly followed by the elicita- 
tion of friction sounds and a palpable parchment crepitation. It must be re- 
membered that severe derangements in the permeability of the intestine may 
sometimes be caused by adhesions. 

C. RELAPSE 

In hereditary syphilis, just as in the acquired form relapse occurs in a cer- 
tain number of cases which cannot be estimated with numerical exactness. Its 
appearance during the first period is frequently in the form of an eruption, and 
usually of a milder type than that of the primary attack. In addition, there 
is a recurrence of coryza, fissures, and onychia. Condylomata us syphilis and 
mucous patches (plaques muqueuses) also play an important, and ultimately 
a predominant or exclusive role, frequently combined with general or local 
extensive swelling of the lymph glands. The period of condylomata, and with 
this the danger of contagion, continues to about the fourth year of life. From 
that time the symptoms of lues tarda are to be expected. 

If several relapses succeed one another a general abatement of their severity 
will usually be noted. 

Deep processes, particularly in the internal organs, may occur in combina- 
tion with this regular form, or exceptionally even alone. Apart from transi- 
tional forms, they no longer possess the character of diffuse infiltration, but 
instead they represent gummata or syphilitic vascular disease. 

The juxta-epiphyseal inflammation of the bones, previously described, is 
again present, while the pathognomonic diaphysial periostitis of lues tarda 
remains absent. Exceptionally there are circumscribed tophi of the cranium 
or tumescent gummatous nodules on the bones of the thorax and in the face. 
Disease of the bone marrow may occur as circumscribed gummata of the spon- 
giosa or a diffuse caseous osteomyelitis, which I have noted also in the diploe 
of the skull. 

Gummatous nodules, which occasionally ulcerate, have been observed in the 
shin. Of other organs only the testicles appear to be affected with any fre- 
quency, and during the first period of eruption are seldom involved to a 
demonstrable extent. Here either nodules are found which occasionally, un- 
dergo ulceration and discharge externally, or there is diffuse nodular infiltra- 
tion, sometimes accompanied by effusion into the tunica vaginalis. Quick and 
energetic treatment is necessary on account of connective tissue degeneration, 
which may cause a loss of function. 

The condition of the eyes must also be considered. Here, besides iritis 
and parenchymatous keratitis, we find a focal choroido-retinitis of pathog- 



324 HEREDITARY SYPHILIS 

nomonic importance. The views in regard to its frequency are divided. Ac- 
cording to Silex it is rare; Hirschberg claims it to be common. Next to kera- 
titis I have found it to be the most usual of all the late symptoms of hereditary 
syphilis. It begins in the fifth month and is indicated by squinting or hold- 
ing of the head slant-wise. All other organic diseases must be regarded as 
rarities. Gummata of the kidney, of the adrenals, of the intestines, of the 
liver, of the spleen, etc., have been reported. Extensive vascular disease may 
lead to contracted kidney (Massolongho). The same process was found by 
Berghing in the heart in combination with well-marked muscular degenera- 
tion; during the life of this 7-months-old child there had been attacks of cya- 
nosis and dyspnea. Death occurred suddenly in the midst of apparent health. 
Affections of the larynx do not appear earlier than the second year. 

Among the diseases of the central nervous system which occur as relapses 
there is gummatous meningitis, especially the basilar form; but the more 
common affection is endarteritis with its sequels (epilepsy, idiocy, cerebral 
hemiplegia and diplegia). Heubner observed spasm of the glottis of central 
origin. 

Occasionally, in the earlier relapses, there is great splenic and hepatic 
enlargement, associated with marked anemia. Probabty, instead of specific 
enlargements, these tumors are of the form known as ancemia pseudo-leuccemia 
infantum, which also corresponds with the blood findings. 

D. TOXIC AND PARASYPHILITIC SYMPTOMS 

The view from ancient times has been that the life of hereditarily syphilitic 
infants is endangered to a far greater extent than that of healthy children, a 
fact which finds its expression in the term " poly mortality " of syphilitic 
progeny. 

Two points must be distinguished. 

The principal factors of polymortality are abortions, still-births, and deaths 
soon after birth. Common to all is the severe affection, fetal syphilis, from 
which the fatal outcome is not surprising. For example, in 153 pregnancies 
Le Pileur found abortions and still-births in 78.4 per cent.; 16.4 per cent, of 
the children died post partum, and only 5.2 per cent, survived. 

However, a further factor had to be considered. It became obvious that 
even mildly syphilitic children and those who had never presented the symp- 
toms of disease, but whose parents were infected, showed deficient development. 
The impression was conveyed that we were dealing with an unusual loss of 
resistance to pathologic influences which permitted an extraordinary acquire- 
ment of severe intestinal catarrh, pulmonary affections, and sepsis. Sudden 
and unexplainable death was believed to be remarkably frequent; but above all 
there was thought to be a conspicuous tendency to severe anemic and particu- 
larly atrophic conditions, which was more common in artificially nourished 
children than in those who were breast-fed, and thus led to the idea that arti- 
ficial feeding Avas a serious menace to body and life. 

The polymortality was likewise manifested in this second group. Even 



SYPHILIS OF NURSLINGS 325 

those individuals who fortunately escaped were said to be feeble, poorly de- 
veloped individuals in later life. 

Therefore the conclusion was reached that a syphilitic descendant shows a 
specific loss of resistance, a specific " debility," upon the basis of which dele- 
terious factors that are readily overcome by those not subject to syphilis pro- 
duce unusual effects. 

These conspicuous phenomena were explained by an assumed toxic " para- 
syphilitic" function of the malady (Fournier) : In consonance with this in- 
genious hypothesis the sperm or ovule, or both, may be " depraved " by the 
disease of the parents ; they are subject to a toxic, protoplasmic damage which, 
although too slight to cause death, nevertheless exerts a f( dystrophic " influence 
throughout the development of the embryo. This leads to deformities and 
retarded growth, general feebleness of cell function, probably also to a special 
debility of individual cell territories which, combined with slight alterations 
of other kinds, produces an acute or slow arrest of function. Therefore para- 
syphilis may be hereditary. It may, however, also arise in the hereditary florid 
disease as the consequence of toxins formed within the body, as in the acquired 
form, or both conditions may occur together. 

This is the generally accepted law of parasyphilis, but many new facts have 
arisen which are calculated to shatter this view. 

First, we must exclude from these considerations all cases which present 
florid symptoms at the outset. If in such children we find a general damage 
the other factors are of greater moment than where there is a parasyphilitic 
injury of protoplasm. Severe conditions are observed mostly in children with 
visceral syphilis, but here not so much the disease itself is the cause of the 
cachexia as the functional disturbance of vital organs. Even breast-fed chil- 
dren cannot always be saved. There are cases, however, in which energetic 
treatment clears up the condition and henceforth there is general improvement 
and development. 

In the ordinary form of infantile syphilis, in relatively severe cases, there 
appears to be a certain arrest of weight during the eruptive period, as in adults, 
which may be due to the general damage; but uncomplicated cases, therefore 
those which are entirely free of criticism, are difficult to find. For the milder 
secondary phenomena, judging by numerous observations of my own, such an 
inhibitive influence does not exist. The increase in weight may proceed un- 
interruptedly. I do not hold the prevalent opinion that in atrophic children 
the simultaneous eruptions and atrophy disappear under mercurial treatment, 
provided, however, we are not dealing with the aforesaid cachexia of visceral 
syphilis. 

In regard to actual parasyphilis, irrespective of obvious products of the 
disease, it must be admitted that in some cases we cannot arrive at a conclu- 
sion without assuming an actual decrease of resistance. Here, however, as 
Finger has recently made clear, it is difficult to separate the condition depend- 
ent upon syphilis from that due to other concurrent predispositions which fre- 
quently act in the same manner (alcoholism, lead intoxication, tuberculosis, 



326 HEREDITARY SYPHILIS 

neuropathy). A point of importance is this, that a like inferiority occasion- 
ally appears in families not so predisposed, and again that in many syphilitica 
it is absent. 

However, for most of the conditions, and particularly for those which pre- 
vail in nurslings, the assumption of such a specific weakness may be dispensed 
with. Sudden deaths and severe anemic conditions are common in non- 
syphilitics. The increased predisposition to disease and in particular the 
tendency to atrophy remain to be explained. 

The belief in these is based largely upon the observations of hospital phy- 
sicians and principally the older ones, to whom the excessive mortality of 
syphilitics appeared to require additional explanation. It is known, however, 
and in the last few years has been the subject of particular discussion, that 
non-syphilitic infants also show an extraordinarily high mortality in institu- 
tions. If the conditions are so far improved for the latter that a decreased 
mortality results, the syphilitic children likewise participate in the improve- 
ment. I have observed such changes myself and now meet with the same suc- 
cesses in the hospital with syphilitic children as with others. Naturally, this 
is also true in private practice. I entirely agree with Freund's statement that 
under similar conditions the outlook for the syphilitic and the non-syphilitic 
scarcely differs. I say " scarcely " with intention, for some reserve is neces- 
sary. There is undoubtedly a predisposition to purulent infection and sepsis, 
which produces an increased mortality. The greater frequency alone would 
not explain a specific loss of resistance; in syphilis it might be accounted for 
by the more numerous ports of entrance (erosions, fissures, etc.). It is true, 
the sepsis of syphilitics runs a severe course, so that the idea of a decreased 
resistance is hard to reject. Almost all of my fulminant cases, especially when 
associated with hematolysis, occurred in syphilitics. 

Particular emphasis must be given to the fact that better results in the 
raising of syphilitic children are also obtained from artificial nourishment. 
The number of authorities who more or less strongly uphold the utility of this 
method is increasing. Even Fournier, the author of the term " parasyphilis," 
has lately been inclined to admit that in this form the advance in knowledge 
appears to have brought about changed conditions. 

The conclusion, therefore, is this: "In so far as the actual polymortality 
exists it is due, in addition to abortions and still-births, to the " projection " 
of visceral syphilis in infancy. Children who are free of this show no essential 
difference from the non-syphilitics in their vitality apart from an increased 
disposition to septic diseases. 

E. MIXED INFECTION 

The uncommonly rich symptom-complex of this disease is still further di- 
versified by the previously mentioned predisposition to septic infection which, 
either local or general, may occur with remarkable frequency in all of its forms, 
preferably during the early eruptive period. The many ports of entrance in 
the skin and mucous membrane, and, not least in importance, through the 



SYPHILIS OF NURSLINGS 327 

nose, give uncommon facility for its development. Of the several forms only 
two will be mentioned: First, purulent synovitis, which is often associated 
with true syphilis of the bones and complicates its clinical picture. This 
probably is never of a specific nature but is a secondary invasion to be ascribed 
principally to streptococci. 

Second, hemorrhagic syphilis of infants must be mentioned. Hemor- 
rhages which closely resemble the hemorrhagic diathesis are particularly com- 
mon in the syphilitic nursling. The hemorrhage increases from petechias to 
large and uncontrollable effusions into the skin, the outer and inner surfaces 
of which present all the gradations of bleeding. Death may occur by hemor- 
rhage from an umbilical wound. Behrend has believed it necessary to distin- 
guish a special form of syphilis by these symptoms and many opinions have 
been expressed for and against his view. 

Some authors (Schiitz, Mracek, more recently Esser) assign the cause of 
hemorrhage to a disease of the vascular walls without, however, explaining that 
local hemorrhage may occur in this way but never a general hemorrhagic 
diathesis with decreased coagulability of the blood. 

Other authors (Fischl) doubt the importance of vascular changes, and 
the majority of them believe that a complication with some other cause of 
hemorrhage is much more likely. Upon the basis of bacteriologic investiga- 
tion in six of my own cases, the result of which is well supported by the litera- 
ture, I believe that, in so far as we are not concerned with stasis hemorrhage 
in hepatic cirrhosis, this other cause, in most or perhaps in all of the cases, 
originates from a secondary septic infection, which, for unknown reasons, in 
syphilitics readily leads to hematolysis. Accordingly, an actual, severe syphilis 
hemorrhagica does not exist, at least in nurslings. "Whether relatively insig- 
nificant petechial hemorrhages or hemorrhagic exanthems are sometimes pro- 
duced by the specific visceral changes, to which Mracek alludes cannot at pres- 
ent be determined. 

F. DIAGNOSIS 

No special explanation is required of the importance and under some cir- 
cumstances of the serious consequences, not only to the child but to the rela- 
tives, and also to the physician for other than therapeutic reasons, which attach 
to the recognition or non-recognition of a disease of such virulent infection 
and of such great influence upon family relationship. From the foregoing we 
have learned what anamnestic and clinical data, from the period of incubation 
until the symptoms are fully developed, are required for a diagnosis, or at least 
a well-founded assumption. But even in the days which are free of symptoms 
— in the interval between the relapses — there are a number of changes, individ- 
ually ambiguous or meaningless, which may be somewhat suspicious when 
they are combined, even without a knowledge of the history. 

These, in the order of their importance, are anemia, especially with a yel- 
lowish hue, splenic tumor, greatly enlarged cubital glands, alopecia, the down- 
ward glance resembling hydrocephalus, the more or less accentuated saddle- 
nose, contraction of the nasal passages, and radiating cicatrices which extend 



328 HEREDITARY SYPHILIS 

from the red lips into the neighboring skin. The traces of earlier fissures are 
especially significant at this age, when other causes of cheilitis are rare. The 
consideration of these symptoms will furnish a correct explanation of many 
of the late localizations of the disease and prevent the serious error of employ- 
ing a wet-nurse. 

It is well, perhaps, to mention some of the conditions which have frequently 
led to an erroneous assumption of syphilis. Every hindrance of nasal respira- 
tion and every rhinitis in early life cannot be attributed to syphilis. In 
many healthy newborn infants and those of premature birth there is a certain 
degree of dry swelling which causes snuffling and probably is the consequence 
of congestive and desquamative conditions. Congenital adenoid prolifera- 
tions may also cause error. The secretion of simple acute coryza is more pro- 
fuse, thinner, and non-hemorrhagic, and is usually associated with catarrhal 
changes in the pharynx. Septic, diphtheritic, and gonorrheal rhinitis must 
also be considered. 

The artificial ulcers of Bednars aphthce, and the thickening of the lingua 
geographica, which is so common, are often mistaken for syphilitic plaques. 
An ulcer on the heel occasionally is given the same importance, and the ulcers 
of ecthyma are sometimes regarded as ulcerating syphilides because of their 
similar shape. 

The glistening redness of the soles of atrophic children is very often 
ascribed to syphilis, but the diffuse plantar infiltration and typical coarseness 
and desquamation of syphilis are absent. More comprehensible is the inclu- 
sion of some peculiar forms of intertriginous eczema which are gradually 
distributed from the boundaries of the diffuse macerating surface as papulo- 
squamous, sometimes as eroded efflorescences varying from the size of a pin- 
head to that of a lentil. These closely simulate syphilitic eruptions and may 
by confluence become annular and scaly, and in cachectic individuals produce 
superficial ulcerating infiltrations which resemble serpiginous exanthems. 
The absence of other stigmata, the limitation to the vicinity of actual inter- 
triginous areas, the exemption of the palmar and plantar surfaces, as well as 
the ineffectiveness of specific treatment, make the differentiation not alto- 
gether difficult. 

G. PROGNOSIS 

In a prognostic respect we are least interested in the outcome of the dis- 
ease. That question can be answered briefly. The ordinary forms heal rap- 
idly and completely even when there is involvement of bone. For the visceral 
forms the verdict must be the same as in homogeneous affections of later life. 
In how far the question of nutrition modifies these views has already been 
touched upon. 

Much more essential are data which will sustain a general opinion as to the 
later progress of the case. Will a relapse occur, and when is it to be expected? 
What likelihood is there of a syphilis tarda? Does the congenital disease 
notably diminish the prospect of life? Can a healthy and normal human being 
eventually develop from the little diseased patient? 



LATE SYMPTOMS OF HEREDITARY SYPHILIS (LUES TARDA) 329 

Very little knowledge is available for the decision of these questions. In- 
vestigations which must necessarily be continued for many years have as yet 
been made by few physicians (Hochsinger, Karcher, Pott). We owe the most 
valuable researches to Hochsinger, who followed the history of sixty-three 
individuals for four to twenty years. Therefore, there is still a hiatus which 
might be filled by experienced family physicians, who certainly could give 
valuable information on the subject. 

It is a conspicuous fact that the generally unfavorable reports which relate 
to the future of infants, and also of older children, are in no wise substantiated 
by actual close observation. 

Relapses apparently do not form the rule, and are probably less likely the 
milder the case. Hochsinger reported relapse in about one-third of his cases. 
In view of this comparative rarity it is interesting to note that among the in- 
mates of hospitals there are fewer relapses than there are first eruptions. In 
85 cases of syphilis which occurred during the first three months of life I 
observed only 20 relapses between the sixth and fifteenth months. Naturally, 
the death of many young infants must be included in this reckoning. 

One relapse only may occur ; on the other hand very intense symptoms, 
especially condylomata, may constantly recur. After the first period the free 
interval is rarely less than three months and may be twice as long. After the 
first year, during which 70 per cent, of all relapses occur, the probability of 
new eruptions is slight. 

According to unanimous reports lues tardea seldom appears after the fourth 
year, — the end of the condylomatous period. Of Hochsinger's 63 cases only 10 
were affected after that period and the author believes these had been treated 
late or insufficiently. 

Therefore congenital syphilis is undoubtedly curable. The children may 
become healthy and even robust. The number of weak, anemic individuals is 
no greater among syphilitics than others. Whether among syphilitics there is 
a general infantilism x or only the organs of generation are affected ; whether 
protracted puberty and other inhibitions of development are more frequent and 
in causal relation, is uncertain. It is doubtful whether there is a special pre- 
disposition to tuberculosis, as some investigators accept 



III. LATE SYMPTOMS OF HEREDITARY SYPHILIS (LUES TARDA) 

As previously mentioned, in children who are hereditarily syphilitic new 
symptoms occasionally appear after the period of relapse — usually from the 
fifth year — which, in their nature and course, show an astonishing uniformity 
with the tertiary products of the acquired disease. 

These late forms cannot be conclusively designated as syphilis hereditaria 
tarda, as that condition is defined quite differently by a number of experienced 
observers. According to these authors syphilis tarda does not include the late 

1 Here, naturally, we do not consider individuals with cicatrized atrophied testicles. 



330 HEREDITARY SYPHILIS 

relapses, but runs a peculiar course, the first manifestations of which generally 
are the tertiary phenomena, while during the suckling period no symptoms are 
present. The actual existence of this tertiarisme d'emblee with its postulate of 
a surprisingly long latency — an absence of secondary symptoms — is still a 
debatable subject, and so far it has not been possible to overcome all the objec- 
tions to such a view. It is true, the eruptive phenomena are often so slight in 
the nursling as to be readily overlooked. In fact exanthems are often absent. 
In one case which I observed from birth to the fourteenth week the child, a 
hereditary suspect, snuffled very little and showed only a slight infiltration of 
the lip, but the finding of an osteochondritis at the necropsy confirmed the 
diagnosis. Death was due to an intercurrent pneumonia. The possibility of an 
intra-uterine termination of the secondary symptoms must be considered. Even 
an early acquired infection, of which there was no knowledge, may in some 
cases be the underlying cause. 

The majority of the late symptoms of hereditary syphilis do not demand 
a detailed description. They resemble the corresponding tertiary phenomena 
of the acquired disease. Periostitis in its several forms — rarefying, ossifying, 
gummatous — is especially frequent and well-marked, and affects principally the 
tibia, but the lower and upper arm are not exempt. Chronic synovitis and 
arthritic disease are observed under the picture of tumor albus and their bilat- 
eral occurrence raises the suspicion of a syphilitic foundation. Further, Ave 
find gummatous cutaneous and subcutaneous syphilides, and gummatous affec- 
tions of the tongue, and of the mucous membrane of the nose and pharynx, 
associated with necrosis of bone and subsequent perforation and radiating cica- 
trization. Profound affections of the larynx and their product, cicatricial steno- 
sis of the air passages, are important and less rare conditions. Characteristic 
changes of other organs occasionally occur. 

Disease of the internal organs requires more comprehensive study. It ap- 
pears that the liver is affected relatively often, as well in the form of tumor- 
like gumma, which gives rise to lobulated liver, as that of the hyperplastic 
stage of cirrhosis. Many familiar bilious icteroid cirrhoses have also, with 
some justification, been placed in this category. Amyloid disease must also be 
considered. Enlargement of the liver is probably always associated with some 
degree of hard and enlarged spleen. Confusion with sarcoma of the liver, with 
non-specific cirrhosis, and with anemia splenica is very easy. 

Among renal diseases certain forms of infantile contracted kidney are prob- 
ably of syphilitic origin, but in this realm little is definitely known. 

Special importance is attached to late infantile syphilis because of the 
damage to the brain. The number of observations concerning chronic menin- 
gitis and endarteritis has recently increased decidedly. Especially do we know 
that even at this early age the so-called " infantile " tabes, that is, the symptom- 
complex and the progressive paralysis which is closely allied to it, develops in 
no wise rare cases upon a hereditary syphilitic basis (Alzheimer, Thiry, Kal- 
ischer, Brasch, v. Didynski, and others). In a small percentage of cases a con- 
nection with epilepsy can scarcely be denied (Fischl, Bratz and Luth, etc.). 



LATE SYMPTOMS OF HEREDITARY SYPHILIS (LUES TARDA) 331 

For the diagnosis of the specific nature of such changes, which are not obvi- 
ously syphilitic, we are in possession of but little distinctive evidence in addi- 
tion to the history. Cicatrices, radiating from the red of the lips, or cicatricial 
bands are significant, but, since profound cheilitis occurs in scrofula and in the 
course of severe infectious diseases, their importance is decidedly lessened. 

Much dis ri: ion has been devoted to the diagnostic value of Hutchinson's 
triad: Keratitis inter stitialis, central deafness, and a peculiar deformity of the 
teeth. 

A resume of the numerous reports of experienced physicians would proba- 
bly show that keratitis inter stitialis, the most prominent link of the triad, al- 
though not constantly of syphilitic origin, is nevertheless so in a vast majority 
of cases and is of great diagnostic significance. Next to keratitis in importance 
is a certain form of choroiditis areolaris characterized by multiple small foci. 
Deafness is much less common and is not in itself exclusively a syphilitic find- 
ing (Schwabach). The importance of tooth deformities is diminished because 
they possess no complete pathognomonic individuality. In hereditary syphilis 
there are various disturbances of growth and other changes in the teeth, but 
on the other hand analogous conditions may be produced by nutritive derange- 
ments. Only one form is to be regarded as at all characteristic ; here tfye perma- 
nent teeth, particularly the central incisors of the upper jaw, show usure or a 
facet which is more marked posteriorly than anteriorly and causes a notched 
or semilunar cutting edge. Such a phenomenon is, however, rare. 

IV. TREATMENT 

Prophylaxis. — In so far as possible the physician should endeavor to pre- 
vent the procreation of children who in all probability will be syphilitics. 

When mag syphilitics marry without endangering wife and children? As 
a rule there is no reason to prevent the marriage of males who have been thor- 
oughly treated, whose infection antedates at least four years, and who have had 
no relapse for two years. A renewal of the treatment shortly before marriage 
is advisable. Frequent relapses prolong this period accordingly. In adhering 
to this minimal period, even without being called upon directly to decide the 
question, we must not permit ourselves to err by the knowledge that ill-advised 
or wilful patients occasionally rear healthy children even when they have been 
recently infected. 

If married couples consult the physician on account of abortions, still- 
births, or illness of their children, energetic treatment of both parents, or, if 
the mother has not been infected, only the husband, must at once be instituted. 
In a relatively high percentage of the cases the result will be the birth of 
healthy children. How the physician will escape the cliffs of the ofttimes 
awkward situation and reach his goal is a matter for his diplomacy. 

If the mother is already pregnant she should be treated at once. This is 
all the more necessary if florid symptoms are present at the time, but treatment 
must be instituted even when their occurrence can only be surmised by the 
history. There is no uncertainty except in the cases of pure paternal heredity, 



332 HEREDITARY SYPHILIS 

and here also Fournier advises treatment. The form of internal medication 
practised by that author throughout the period of pregnancy 1 is not generally 
accepted in countries outside of France. While in older cases the ordinary 
form of treatment is sufficient, experience has unanimously decreed that a 
mother who has recently become syphilitic has little hope of hearing a healthy 
child. In such individuals BiehPs process 2 — a combination •>* general treat- 
ment with a local application of vaginal globuli — appears to furnish excellent 
results as regards vitality and morbidity. 

Treatment. — In the treatment of children the internal administration of 
mercury and the corrosive sublimate bath are of primary importance, in con- 
trast to the treatment of later life. I prefer the former, as it can be readily 
carried out and is very effectual. The dose per day is 0.01-0.02, administered 
in small amounts and never upon an empty stomach. 

Of the numerous preparations 3 I have employed only hydrargyrum iodid 
flavum (mercury protoiodid), calomel, hydrarg. oxid. tannic, and salicyl., 
which show no noteworthy differences in their action and subsequent effect. 
The protoiodid appears to be particularly energetic in disease of the bones. 

The corrosive sublimate bath* an especial feature of which is its prolonga- 
tion (ten to fifteen minutes), appears to be of greatest value in extensive ex- 
ternal eruptions or when there is decided loss of epidermis (intertrigo and the 
like) ; if such conditions are absent this treatment is probably too slow and 
should be used only as an auxiliary measure. 

All other methods of application are generally regarded as only exception- 
ally of value in the child. Like many other pediatrists, after a brief trial we 
have abandoned the treatment by inunction (0.25-0.5 per day) as it irritates 
the skin too greatly. This treatment is recommended for fat and very robust 
children, and after the first six months if there be relapses. It may be tried 
in severe cases where a quick effect must be obtained. Packing with mercurial 
plaster-mull (Unna), 5 a substitute for inunction treatment, often produces an 
eczema. 

Treatment by injection is inexpedient because of the relatively thin soft 
parts and the possibility of painful infiltrations. 

Siefert's modification of Welander's sack method* and Blaschko's merco- 
lint bandage are suitable occasionally in mild cases. 

As a rule the administration of mercury is well borne by infants. The 

1 Alternate treatment with protoiodid of mercury 0.25 per day and iodid of potas- 
sium 1-2.0 per day. 

2 Wiener klin. Wochenschr., 1901, No. 26. Vaginal globules (Ung. cin., 1.0 Butyr. cacao 
1.0-2.0 daily throughout pregnancy), inserted to the portio and fixed with a tampon. 

3 Compare the compilation of Monti, Kinderheilkunde. in Einzeldarstellungen, II Bd. 
4 0.75-1.0 to the bath. Wooden or enameled tub! Careful handling of the drug is 

demanded. 

5 The four extremities are enveloped in turn and covered with a bandage. The ap- 
plications should be renewed every four to eight days. 

6 Naturforscherversammlung, Sect. f. Dermatol., etc. Munich, 1899. Six to 10 grm. 
Hydrarg. concreta upon the woolly side of a piece of lint (20 x 40), folded and sewed 
into a bag, and tied on. Renew every four to six days. 



TREATMENT 333 

danger of stomatitis and even of marked salivation is so slight that special care 
of the mouth is scarcely required. In inunction treatment Monti warns against 
the possibility of sudden death from cardiac weakness and edema of the lungs, 
but these are probably accidental complications rather than the effect of treat- 
ment. Also the gradually developing anemia can hardly be ascribed to the 
metallic intoxication, as the same symptom is characteristic of syphilis (Schiff ) 
or is due to the intestinal disturbance so frequently associated with the dis- 
ease in infancy. In any event I have never found reason from this to inter- 
rupt specific treatment and administer iodid of iron simultaneously, as advised 
by Monti. Widerhofer's method, however, of combining iron with mercury 
(Ferr. carbon, sacchar., in doses of 0.1-0.2) is quite proper. 

Internal treatment, and particularly the protoiodid, is said to evoke intes- 
tinal irritation. I have never been able to convince myself of the correctness of 
this statement, but do not deny the possibility of such an occurrence. Despite 
mercury we very often succeed in improving the condition of the intestines by 
dietetic means. Calomel in small doses is in good repute as an intestinal anti- 
septic in nurslings. For this purpose I employ calomel in combination with 
tannigen (2.4 — 0.005) and have seen excellent results. Some authorities add 
a small quantity of opium. 

The internal administration of mercury prohibits the simultaneous em- 
ployment of salts of iodin and bromin, and vice versa, because of the danger 
of corroding ulcerations of the gastrointestinal canal. Also, the child should 
never have mercury when the nursing mother is taking iodin. 

Treatment with iodin (0.2-0.5 daily) is of little service in the ordinary 
syphilis of infancy. It is to be considered in those forms which, like many of 
the relapses, resemble the gummatous stage of later life, and is especially useful 
in the rare cases of syphilis of the brain. Under such circumstances a mixed 
treatment in the most serviceable and in the severe cases inunctions are pre- 
ferred. In young children prolonged iodin medication may greatly interrupt 
the gain in weight. 

Important local affections are treated in the same manner as in the adult : 
covering marked infiltrations (onychia, etc.) with gray plaster, dusting the 
condylomata with calomel after cleansing with normal salt solution, etc. The 
fissures of the mouth are treated' advantageously with a 10 per cent, solution 
of chromic acid, the surrounding skin being carefully avoided, or with a one 
per cent, corrosive sublimate solution. In the nose mercurial salves may be 
applied, after softening the crusts. The nasal affection is exceedingly tena- 
cious. Here great benefit has resulted from painting with solutions of silver 
nitrate (0.5-15), as advised by Henoch, and in the clinic we have utilized this 
remedy successfully by spraying 1 with a solution of 1 to 1,000. 

The influence of specific treatment becomes noticeable in a few days. The 
exanthem fades, new eruptions do not appear ; fissures and mucous plaques are 

1 The child is held by the nurse with its head over a basin, so that secretions and 
fluid may flow through the mouth or nose. 



334 HEREDITARY SYPHILIS 

distinctly improved after a mercurial treatment of four or five days; in the case 
of pseudo-paralysis movement returns with surprising rapidity. Rhinitis, as 
already mentioned, is much more tenacious, and it is not unusual for a snuffling 
respiration and a nasal timbre to remain for some months after the secretion 
has been arrested, perhaps as the expression of a chronic, non-specific prolifera- 
tion of the mucosa or of the pharyngeal tonsil, or of permanent stenotic change 
in the bone. The visceral forms appear to require a comparatively long treat- 
ment before improvement is noted. 

This leads to a few words as to the length of the treatment. In general it 
has been found advisable to continue treatment for two weeks after all the 
symptoms have entirely disappeared. This usually requires five or six weeks. 
Nevertheless, according to my experience it is doubtful whether this period is 
sufficient for profound changes which may have occurred. For example, in a 
child who perished from an intercurrent disease a fortnight after a six weeks' 
treatment with protoiodid of mercury and four weeks after the disappearance 
of all exanthematous symptoms, I found a decided osteochondritis. As the 
certainty of the absence of important visceral processes is never absolute, even 
when symptoms no longer exist, prolonged treatment is advisable, of course 
within the limits of intoxication. 

Whether, in the absence of a relapse, renewed treatment should be instituted 
in the same manner as the intermittent treatment of adults, and whether by 
this means relapses are more apt to be avoided, cannot be asserted positively. 
Most authors favor a second treatment after the first year, and again in the 
second and third years. Monti believes that the administration of iodid of 
iron} continued until the disappearance of the anemia and splenic tumor, has 
a preventive effect. 

Nourishment. — The nourishment of hereditarily syphilitic patients presents 
certain peculiarities which are of salient practical importance and must there- 
fore be explicitly described. 

Most text-books and many physicians oppose artificial nutrition. They 
claim that this is dangerous to life as the constitutional weakness of the child 
has already enhanced the possibility of failure. Upon the other hand the 
threatened transmission precludes the employment of a wet-nurse in case the 
mother cannot nourish her child, and even the mother is not always immune 
from infection. In the face of such a dilemma the active discussion regarding 
the principles which are to govern the decision of the physician can readily be 
understood. 

If the mother can nourish her child the decision is simple. According to 
Colles's law, when the mother has never manifested symptoms she is usually 
exempt from contagion. Nevertheless a few exceptions are known: Primi- 
parse, in whose children a late appearance of the symptoms shows them to be 
mild, have been infected through nursing. It is easily understood that in such 

1 0.1-0.2 once to three times daily according to age. It must be remembered that, 
according to many syphilographers, iodin alone has no protective power against re- 
lapses, this being the property of mercury alone. 



TREATMENT 335 

cases the immunization of the mother has not been sufficiently long and has 
been maintained by a poison only slightly active; therefore, sufficient protection 
has not been conferred. This possibility is not considered by most authors in 
practice, and is so rare that a man of Fournier's experience has not observed a 
case. Hochsinger alone is absolutely opposed to a healthy primipara nursing 
her sick child. 

Contrary to Profeta's law, contagion has sometimes happened to the child. 
Because of its rarity the removal of the infant from the breast is not necessary. 
The danger of infection from other contact is much greater and its prevention 
is more important than a prohibition of nursing. In late post-conceptional 
syphilis of the mother Czerny and Keller advise that she should not nurse the 
child. 

What shall be the procedure when the mother cannot nourish her child? 

On account of the great danger of artificial feeding many authorities advise 
a wet-nurse. They reckon upon the comparative rarity of infection (Henoch, 
Widerhofer), or recommend that the decision be left to the wet-nurse after the 
condition has been explained to her. 

Anyone who has the temerity to expose a healthy person to infection, to 
risk infection not only of the nurse but others, and hereditarily of an entire 
family, he who desires to escape responsibility by leaving the decision to one 
incapable of forming an opinion, or who is of the naive belief that after dis- 
closing the state of affairs to the family the necessary discretion of the latter 
can be maintained, may follow this advice. I share in the general opinion that 
under no circumstances is such a method justified and that artificial nutrition 
is the only recourse. This decision should not be difficult, because, as has al- 
ready been stated, with a proper method of nourishment there is no more 
danger to the syphilitic child than to the non-syphilitic. 

Therefore, no wet-nurse — not only when we are dealing with manifest 
syphilis, but even when the child shows no evidence of disease at birth but 
whose family history is known. When infection occurred many years previ- 
ously perhaps an exception might be made. If the eruption appears during the 
period of breast-feeding the nursing must be stopped at once, as soon as the 
first symptoms appear; we must not wait until a typical exanthem is present. 
The opportunity for withdrawal of breast nourishment may perhaps be brought 
about by difficulty in suckling due to coryza and fissures. 

There will always remain a proportion of syphilitic children — premature 
births and cases of severe visceral syphilis — whose improvement is essentially 
more hopeful when they are nourished with human milk; milder cases thrive 
with the bottle. With natural nourishment only may we hope to maintain 
them until a therapeutic influence is exerted. In such cases a means must be 
found of administering milk that is drawn from the breast. 

The symptoms of lues tarda are favorably influenced by iodin (1-2.0 daily). 
Progressive and visceral forms require a mixed treatment which may be con- 
ducted advantageously in the regions of iodin springs (Tolz, Heilbronn, Hall). 

[The treatment of pregnant syphilitic women must be persistent; particu- 



336 HEREDITARY SYPHILIS 

larly of those who have aborted previously. Even though they cannot be seen 
and watched regularly, no harm can be done. Salivation can be avoided. It is 
my habit to give them an iodid and the yellow iodid of mercury in alternating 
weeks for many months in succession, for instance the first, third, fifth, fif- 
teenth, etc., week or 15 or 20 drops of the potassium, sodium or stronthium 
iodid saturated solution 2 hours after a meal, 3 times a day; the second, fourth, 
sixth, sixteenth week 1 or iy 2 grains of the protoiodid of mercury daily, in 
three pills, to be taken in the same way. I generally add a small dose of an 
opiate or of atropin to each pill. 

The facility and safety of mercury when the patient is a newly born or 
small child, salivation (gastritis or enteritis being almost unheard of), facili- 
tate and advise protracted treatment. I am never satisfied with the disap- 
pearance of manifest symptoms of syphilis, but continue treatment for several 
months uninterruptedly, then intermit a month, and begin again in alternating 
months. After a while it is safe to mediate a month out of three. Unfortu- 
nate experience has prevailed upon me to give mercury several months in the 
second and in the third year. — Editor.] 



SPEECH DISTURBANCES OF CHILDHOOD 

By H. GUTZMANN, Berlin 

The child attains the faculty of speech a long time after birth, slowly, 
just as it learns the movements of walking, running, grasping, and holding. 
Speech itself is only movement, although quite complicated and highly coordi- 
nated. The three great musculatures of respiration, voice and articulation 
must be induced to a common activity; the gradations of muscular movement 
of the voice and of articulation are so fine that with a relatively slight muscle 
sense in these parts the art of speech will be accomplished but slowly and 
laboriously. The newborn child is mute, and since in the first days a great 
number of children at least seem to hear but little or not at all, we have not 
alone a physiologic mutism but a physiologic deaf mutism of the newborn. 
How the senses gradually develop, in what manner the faculty of perception 
arises, how, upon the basis of these the conceptions become manifold, and are 
profoundly and more intimately associated, and how, finally, the function of 
volition springs from this psychic structure, furnishes a great and inter- 
esting realm in the psychology of the child. In the works of Steinthal, 
Lazarus, Preyer, Goldammer, Yierordt and, last not least, Kussmaul, will be 
found a great number of individual observations and careful descriptions of 
this psychologic order of development. When we concern ourselves more 
minutely with these questions we shall find that almost all errors of articula- 
tion of children may be referred to certain physiologic disturbances in the 
development of speech. I say physiologic disturbances because they must 
necessarily arise with development; and, in order to completely appreciate 
their value and influence upon the further speech activity, a brief consideration 
of these processes is necessary. This will at the same time serve as an intro- 
duction for a sensible and complete prophylaxis of speech disturbances of 
childhood, and here it may be stated that almost all speech disturbances con- 
sidered in this article can be prevented by this prophylaxis. 

The development of speech may be divided into four distinct parts, although 
as to time they are not so separated that one period begins as another closes. 
The first division is the crying period. Even the ancient philosophers have 
debated the causes of crying in children and have offered the most compli- 
cated theories in explanation. Thus, children were said to cry because they 
felt in advance the misery of the world that awaited them ; they cried in pro- 
test at coming into such a world; and it was even held that the cry of the 
boys was " oh ah," the girls more like " oh eh." As the newborn child naturally 
23 337 



338 SPEECH DISTURBANCES OF CHILDHOOD 

could not be expected to speak a fluent Latin this was interpreted to mean 
" o Adam cur peccavisti ! " and " o Eva cur peccavisti! " The crying of an 
infant is certainly an indication that it is dissatisfied. The negative sense of 
being completely dominates it. In its relation to speech this crying epoch 
has special importance, as the respiration of crying is preliminary to later 
speech respiration. The infant cries in prolonged tones, which are frequently 
interrupted by a short intake of breath. These inspirations are through the 
mouth, while in sleep and when it is otherwise quiet, the child breathes through 
the nose. The ratio of inspiration and expiration of crying is that the former 
is short and through the mouth, the latter quite prolonged but also through the 
mouth. This is likewise the type of the later speech respiration. We are there- 
fore justified in regarding the respiration of crying as preliminary practise for 
speech respiration. The longer the expiration during crying, the better for 
the later speech; if the expiration is prolonged, many words can be uttered 
during a single breath, and the better we can control the breath the more fluent 
will be our speech. Practise of the voice, which is a feature of crying, is by 
no means purposeless; the strengthening of the voice which thus results, the 
delicate tone which is heard in the softest expiration, are preliminary exer- 
cises of great importance for the later speech. We shall not discuss the influ- 
ence of crying upon the general development since that is beyond the confines 
of our subject. 

When the child has become more tranquil and begins to take an interest 
in its surroundings it often lies awake without crying and attempts, besides 
movements of the arms and legs, also to employ its organs of speech. Quite 
unconsciously the first developed sounds bear a very uncertain character and 
are produced in all portions of articulation, although with a preference for 
the lip and the anterior tongue sounds. Apparently these are muscles which 
the child has used earliest. Sucking is a natural function, for the movements 
which produce it are noted even before birth if the finger is accidentally intro- 
duced into the mouth of the child during obstetrical examination. Among 
the vowels the simplest is a, which requires no other movement than the opening 
of the mouth. This vowel, or at least its modification a, is most frequently com- 
bined with the consonants o, p, m, d, t, n, so that the sequence of syllables such 
as ba-ba-ba, da-da-da, ma-ma-ma, etc., sound like da, da, na, na, etc., which 
is the language of children at the age of three or four months in their afore- 
said quiet condition. Besides these simple utterances we hear, as already 
stated, other articulations, a series of peculiar gurgling and sputtering sounds, 
also sounds that first occur voluntarily much later; for instance, the palatal 
r. The child is sometimes so pleased with this sound production that it crows. 

These articulations are nothing more than congenital instinctive move- 
ments, or, if we desire to maintain the conception that a movement with- 
out preceding stimulation is impossible, they are reactions or reflexes 
following some endogenous irritation. The child and those about it are pleased 
with them, and from the most ancient times the maternal love has attached 
a special meaning to this first childish lalling, in that the mother attempts to 



SPEECH DISTURBANCES OF CHILDHOOD 339 

• recognize her name in these disconnected, groping, ataxic beginnings of speech. 
Thus it occurs that the first childish efforts at speech, which are mostly auto- 
matic or reflex, very soon attain the importance that those around the child 
attach to them. The syllabic sequences ma-ma-ma, ba-ba-ba were declared to 
be the names of the mother and father, a meaning which the child had not 
yet attached to these sounds. We must not, therefore, consider it remarkable 
that the names given by children to their parents are the same or very similar 
in almost all languages, not alone of civilized peoples but also of the 
aborigines. Papa and mama are not only the names of endearment in Eng- 
lish, German, Russian, and French, but also in the language of the natives of 
Central Brazil, of the " Bakairi " and " Trumai," in the speech of the negroes 
of Africa, of the South Sea Islanders, and elsewhere. Often, instead of papa, 
it is baba or bawa, instead of mama it is papa, menie or erne, also mene and 
similar sounds, but always the names of the father and mother are a sequence 
of sounds which correspond to the first Jailing of the child. It will thus be 
observed that the child creates its own language, and often when we investigate 
and ponder over the origin of words, an expressive answer would be given by 
pointing to a child who is learning to speak. In the speech development lies 
the simplest solution. Kussmaul describes this epoch in the linguistic devel- 
opment of the child as the period of original or natural sounds. Perhaps a 
better designation would be the period of reflex speech. 

Meanwhile the mental faculties of the infant have markedly developed. 
The organs of special sense, which at first only apperceive, now begin to appre- 
ciate: sight has generated observation, listening is developed from hearing, 
touch produces sensation, and eating creates taste. Thus the organs of sense 
are daily unfolding their object: to construct the complete psychical world of 
the child and to bring the individual perceptions into relation. The great 
realm of the association of the individual expression of the senses builds itself 
in sequence. The child now not only hears but listens, that is, hears atten- 
tively, it now not only sees but observes, therefore, sees attentively, so that a 
very remarkable phenomenon — imitation — arises which may be regarded as a 
kind of higher reflex. In a stimulation of the sensory impression is also found 
the impulse which produces the reflex, that is, the cause of the movement. 

What appears in imitation as such a remarkable power we can distinguish 
better and more simply as the force under which a reflex movement appears 
through stimulative impressions. The child sees movements and imitates 
them; it hears sounds and at once attempts to repeat them in so far as its 
skill and capability of coordination of the organs of speech permit. In the 
growing child the desire to imitate bodily infirmities, such as squinting and 
limping, is very common. It is also well known that general nervous spastic 
phenomena, for example, chorea, may become epidemic in schools. 

In some individuals the reflex movements respond to stimulation rapidly, 
in others more slowly. This is also true of the power of mimicry which in 
in some children responds early and energetically to sensory impressions, 
while in others it is retarded and awkward. To comprehend this peculiar 



340 SPEECH DISTURBANCES OF CHILDHOOD 

variation we must remember that children, even relatively early, are able to 
understand a great many words before they can voluntarily pronounce them. 
It will not be without interest to investigate this faculty of word perception 
in a child about 10 months. When it is quiet and attentive its comprehension 
of words can readily be tested, as a child will look toward an object usually when 
it recognizes the word which designates it. Naturally apperception is neces- 
sary in this test; mere perception is not sufficient, as the child varies greatly 
in its attention. Thus knowledge and understanding of a word will be demon- 
strated by a turning of the eyes toward the object mentioned which at another 
time may not occur. If this experiment is continued patiently and with perse- 
verance, and is done as if in play, without tiring the child, a clear insight of 
its sensory accumulation of words will be obtained; we will discover which 
sounds have already made so profound an impression that their repetition at 
once awakens the memory of something known. In the normal child this rela- 
tively early cultivation of the sensory speech center is never accompanied by 
a corresponding development of the center for motor speech. It appears 
almost as if the stacking of word sounds propagates the endogenous stimula- 
tion for the development of the motor center. However, the child must eventu- 
ally endeavor voluntarily to imitate what it has perceived in its surroundings 
as regards speech production, and the many defects in these early, grop- 
ing, ataxic efforts cannot appear especially remarkable, since the other 
movements, such as grasping and walking, are at first extraordinarily ataxic 
and only develop into coordinated movements after much exercise and many 
failures. 

This period of imitation, the third therefore in the evolution of speech, is 
probably the most important in the entire development; for now, if at all, 
there is opportunity for the child to acquire errors, or to absorb the impercep- 
tible germ of faulty speech development. This imitation must follow a model. 
If the model is poor, if it is in any way abnormal, we must not be surprised 
when we find anomalies in the subsequent speech of the child. The better the 
example, therefore the more distinct the articulation of those who are about the 
child, the clearer their syllables, and the more beautiful their language, the 
more certain may we be that the little mimic will acquire good speech. 

It will therefore be recognized that the movement toward a natural prophy- 
laxis of speech disturbance must begin in this period of imitation. The en- 
vironment of the child offers the first impetus for the acquirement of speech 
defects, regardless of hereditary predisposition, and the like, which will be con- 
sidered later. 

The second exceedingly important factor in the development of speech de- 
fects is the disproportion, which we have learned to recognize, between the 
growth of the motor and of the sensory centers. If from the well-developed 
sensory center continuous waves of stimulation arise which endeavor to excite 
the motor tract of speech, and if, on the other hand, the proficiency of the 
organs of articulation, the coordination, has not yet been perfected to such an 
extent as to translate this stimulation to corresponding movements, we must 



SPEECH DISTURBANCES OF CHILDHOOD 341 

not be surprised if errors of the most varied nature arise in the speech develop- 
ment. The child often makes mistakes in speaking ; perhaps it uses the wrong 
term; or if the word is improperly produced it repeats the initial syllable or 
sound, at first without special stimulation, but later with unquestioned accelera- 
tion of the speech movements. This is primarily a purely physiologic pecu- 
liarity which has been closely observed by all of the aforementioned inves- 
tigators of infantile speech. Preyer has quite properly placed these faulty 
articulations in parallelism with the speech disturbances of adults. As the 
phenomenon is at first physiologic it is to be observed in almost all children. I 
have rarely missed this halting early speech in the many investigations which 
I have devoted to the subject. Among others I was able to note it in my own 
children, who learned to speak normally. These little primary awkwardnesses 
have no special significance; but later, when the child endeavors to express its 
sensations, opinions, and thoughts, therefore, as soon as the child's vocabulary 
is sufficiently complete for the expression of its thought, they acquire an im- 
mense importance. This expression of thought is the chief characteristic of 
the fourth period of speech development, and if up to this period the power 
and the cleverness of mimicry have been limited, inhibitions will arise in the 
form of mutism or of stuttering. 

We are often informed by the parents that at first their child was quick 
at imitation and could even pronounce a few words, but that after a definite 
period the words were no longer used and the child has since been almost 
speechless ( deaf mutism ) . 

It might be supposed that this condition has originated from futile attempts 
of the child to imitate the speech of those about it; that in contrasting its 
speech production with that of others it realized its shortcomings without 
understanding them, and finally relinquished its efforts in disgust. This ex- 
planation is not altogether theoretic, but may frequently be confirmed by an 
investigation into the origin of these conditions. A voluntary deafness of this 
kind may arise even later, but there will then be more complicated phenomena 
than in the earlier period of speech development. External factors such as 
adenoid vegetations, malformations of the palate, etc., may facilitate the de- 
velopment of this condition ; in some cases I have found cleft palate to be the 
cause. Naturally these expositions apply only to normal, intelligent children. 
If we are dealing with mild or marked idiocy we must expect to find loss of 
speech and disturbances of articulation. In slight grades of idiocy the general 
awkwardness is very characteristic, and in the extreme types there will be no 
speech, for the simple reason, so aptly expressed by Griesinger, that the child 
"has nothing to say/' 

The innate instinctive movement of the child may be defective without 
any special demonstrable mental disturbance. In some cases we may even ob- 
serve a congenital sluggishness; the child does not learn to walk until late, 
not because of rickets or other disease, but because it does not desire to walk ; 
there is no great wish to move about and therefore no attempt is made to stand 
and to walk, as is the case of a normal child. It may not be without signifi- 



342 SPEECH DISTURBANCES OF CHILDHOOD 

cance to call attention to a parallelism in children learning to walk and those 
who are wilfully mute. Children frequently learn to walk early, perhaps at 
the age of 11 months, but after they have fallen a few times and been hurt they 
do not make a further attempt until a considerable interval has elapsed — I 
myself have seen intermissions of three months and longer. If they are left 
to stand alone they will not try to walk but either sit down at once or begin to 
cry. It would therefore seem here also that a knowledge of failure of their 
efforts inhibits the desire for movement. 

The second and far more frequent evil which arises from interrupted devel- 
opment and which must be referred particularly to the great disproportion be- 
tween the motor and sensory speech centers, is stuttering. These slight repeti- 
tions and numerous trials of speech which with a greatly developed sensory 
speech center become constantly quicker and more active, may readily produce 
a spastic articulation, and we observe a characteristic stuttering, sometimes 
after an evolution of several years, but often in a very brief time. 

Finally, the development of certain speech sounds may be more or less re- 
tarded so that they appear late or perhaps can never be uttered. To this 
category belong especially the sounds of the third domain of articulation, 
1c and g, the fricative sounds s, sch, and others. These slight errors in pro- 
nunciation, which have been included under the collective term stammering, 
are in themselves of no special importance. Naturally, they denote retardation 
of the motor center in comparison to the sensory. They are only of influence 
upon the development of the child when they persist for a long time, for ex- 
ample, until the school years. 

Children who stutter and stammer are but litle conscious of their speech 
defect; they are almost unaware of their shortcoming which is so apparent to 
their playfellows. If, however, this consciousness is awakened by accident, 
.or by a change in the training of the child, for example, entrance at school, 
it has an extraordinarily depressing effect and as a consequence of this depres- 
sion complete mutism, aphasia voluntaria, has not infrequently been noted. 
Those who even superficially study the development of psychical depression 
in speech disturbances will generally acknowledge that simple stuttering may 
lead to mental dejection. That, however, an incorrect pronunciation also pro- 
duces the same result may often enough be demonstrated in practice. I shall 
never forget a case which I saw with the late S. Guttmann: A boy, aged 7 
years, the child of wealthy parents, had been the pet of the family and had 
received instruction at home. At a children's party which he attended at the 
house of some friends several boys noted his faulty pronunciation of the s- 
sounds, and with the lack of delicacy and consideration for others which is so 
common in children, they began to guy him. The lad returned home crying 
and would not reply to questions as to the cause of his sorrow, but sat quietly 
in a corner and refused to eat and speak. After a few exercises the little 
fault was corrected — it was a case of sigmatismus nasalis — and the child was 
as happy as ever. With the removal of the cause the depression disappeared. 
Every error, particularly of speech, which becomes perceptible to the child 



SPEECH DISTURBANCES OF CHILDHOOD 343 

and makes him conscious of his inferiority to his playmates may lead to symp- 
toms of depression. 

It is quite self-evident that the aforementioned defects cannot be attributed 
to physiologic phenomena alone. Apparently there must be some additional 
cause which facilitates the development of the evil. For if the physiologic 
phenomena alone were at fault almost all children would acquire defective 
speech or at least pass through a period of actual speech disturbance before they 
could speak correctly. Although this conception is not generally recognized, 
and although it is proper to refer to physiologic stuttering and especially to 
physiologic stammering in infantile speech development, nevertheless, for the 
generation of the pathologic condition some special disturbance is necessary, 
the nature of which is not always obvious. 

There can be no doubt that by far the greater number of children, and 
especially those who stutter, are of a hereditary neuropathic predisposition, 
and Kussmaul is quite right when he speaks of a congenital irritable tveahness 
of the apparatus of articulation — a weakness which betrays itself by speech 
spasms. Accordingly, those children who acquire stuttering or who have stut- 
tered from the beginning of speech development are, in by far the majority of 
cases, nervous or neurasthenic. These two conditions may quite properly be 
differentiated, in that the nervous child reacts more rapidly and intensely to 
irritation than the normal child; its wave of stimulation lies deeper. The 
neurasthenic child shows, in addition, an extraordinarily rapid fatigue of all 
nerve functions, an abnormal, ready exhaustibility of the functionally stimu- 
lated nerve regions, whereby the nervous apparatus, even after a conspicuously 
slight use, reaches a state of irritable exhaustion (see Krafft-Ebing and Erb). 

A careful investigation of the etiology of stuttering brings us to the con- 
clusion, as Mygind has shown, that the neuropathic predisposition of children 
is an extraordinarily important causal factor in stuttering. The irritation 
itself to which such patients react more rapidly than the normal child may be 
quite obscure to the eye of the investigator. It is true that in children an 
endogenous irritation from the intestine is capable of producing the most 
astounding nervous phenomena, and the older clinicians well recognized that 
stutterers frequently suffer from constipation. The irritation of constipation 
may have a more or less decided influence upon speech provided we are dealing 
with a nervous individual, and for this reason the old pediatrists advised the 
administration of purgatives in the treatment of speech disturbances. A com- 
parison herewith of a remark of Romberg in his Text-Book of Xervous Dis- 
eases of Man (1851) is not without interest. In describing the treatment of 
stuttering he says : " In treatment attention to the causal indication has in 
recent years been too much supplanted by gymnastics of the tongue, and here 
also the futility or even the deleterious effect of the remedial dilettantism is 
evident. According to the requirement general or local venesection is to be em- 
ployed, or integrating stimulation, applications of cold, sea-baths, etc., and 
especially the administration of laxative remedies, which have proved of great 
service even in the most obstinate cases, of which Bostock has reported a very 



344 SPEECH DISTURBANCES OF CHILDHOOD 

remarkable example: Every relapse of stuttering was overcome by the employ- 
ment of purgatives in combination with a strict derivative diet." (History 
of a Case of Stammering Successfully Treated by the Long-continued Use of 
Cathartics. Med. Chirurg. Trans., Vol. xvi, p. 72). The early writers were 
so familiar with this symptom in stuttering children that the ancient thera- 
peutic regime, proposed by Hieronymus Mercurialis, was purely dietetic. 
This author, however, did not neglect exercises of speech nor general physical 
exercise, which he introduced as important measures in treatment. He says: 
Exercendum est corpus, quantum fieri potest, praesertim vero exercenda est 
vox, et si quid est, quod possit prodesse balbis et haesitantibus, est continua 
locutio alia et clam. 

In the cases mentioned the result of irritation from the intestine was the 
appearance of speech spasms in the form of stuttering. But this intestinal 
irritation may also give rise to paralysis of the motor speech tracts, or, better., 
to an excessive stimulation of the inhibitive tracts, so that articulation becomes 
impossible and the picture of aphasia is presented. Thus Henoch has observed, 
aphasia from overloading of the stomach. The aphasia disappeared after 
vomiting and might therefore be called an aphasia dyspcptica. Arndt observed 
aphasia after accumulation of feces, Lichtenstein after nematodes — aphasia^ 
helminthica. I have seen a case of aphasia in a girl, aged 8 years, which was 
produced by oxyuris vermicularis. The aphasia disappeared after the worms 
were removed. These conditions were also known to ancient writers and in 
the Nosologia Methodica of Boissier de Sauvages, among other forms of dumb- 
ness we find mutitas verminosa: " Puer ex amphimerina verminosa mutus 
evaserat; sublata febre mutitas persistit; est post aliquod tempus sumptis 
anthelminticis triginti sex lumbricos intra vaginti dies deiecit, quibus reiectis 
loquela rediit, its tamen ut littera B difficilius pronunciaretur." 

Therefore, in all cases of speech inhibition or spasm we must remember 
that both phenomena may be produced by the same irritation and we must 
judge in the individual case whether such an irritation is to be assumed, as 
in the examples which I have mentioned. 

Among the endogenous stimulations which come under consideration and 
which have a direct relation to infantile speech disturbances, we must consider 
improper feeding. Spastic speech defects are particularly common in children 
of the prosperous classes. In Wiesbaden the statistics regarding the percent- 
age of stutterers among the students attending the Gymnasium showed that 
there were twice as many cases as were found in the public schools. Apart 
from the neuropathic predisposition, which we may assume to be in about the 
same proportion, an improper nutrition is frequently the cause of spastic 
speech phenomena. I have almost invariably encountered over-nutrition with 
meat in nervous stutterers of the well-to-do. That nutrition of this sort cannot 
be counteracted by exercises of speech because it maintains the fundamental 
irritation for speech spasms probably requires no comment. If the nourish- 
ment is changed and the child is given a mixed diet, with limitation of meat 
as much as possible to one meal, the child not only improves in appearance 



SPEECH DISTURBANCES OF CHILDHOOD 345 

in a relatively short time, but increases in weight and, what is most important, 
is more composed. Very little speech exercise is then required to overcome 
the stuttering. This disappears, we might say of itself, with the elimination 
of meat, and according to the conception of stimulation and reflex here given, 
the explanation is simple: The irritation of faulty nutrition is diminished 
and the reaction of defective speech disappears. A classical example of such 
cases will be detailed briefly: 

A boy, aged 8 years — sent to me by Professor Erb — whose mother was ex- 
ceedingly neurasthenic, was accustomed to but little variation in his diet. The 
amount of meat which he consumed in the first three days in my hospital was 
almost phenomenal.; it was sufficient to satisfy a full-grown man. He rejected 
vegetable food as his mother had taught him that this was difficult to digest. 
The boy suffered from constipation, was pale, of small stature, and weighed 
only fifty-two pounds. He stuttered over nearly every word ; sometimes he could 
scarcely speak and had to pause in the midst of a sentence. He was readily 
annoyed by external impressions. Sounds, noise, the boisterousness of chil- 
dren, were unbearable to him. He was not accustomed to romp and play with 
other children; his sleep was restless and almost every night interrupted by 
loud outcries succeeded by weeping. 

Before instituting any treatment in the way of exercise I directed my atten- 
tion to the regulation of his diet. The boy was given food consisting principally 
of vegetables ; the amount of meat was reduced to a moderate quantity at mid- 
day; vegetables of all kinds were given to him, which up to that time he had 
not eaten at all or in only small amounts, and he accustomed himself, although 
at first with some repugnance, to this change in diet. Instead of the glass of 
sweet wine which he had been allowed at home " for strengthening " ( ! ) and 
which, naturally, had increased his nervousness, he was given milk. Morning 
and evening he was bathed in water of the temperature of the room and at 
half -past seven he was compelled to go to bed. As a result of this treatment the 
boy gained in weight, soon had rosy cheeks, showed little or no reaction to exter- 
nal irritation, joined in the play of other children, and — he no longer stuttered. 

When, after a few months, the mother took her child home and asked my 
advice as to the remedies to be used to prevent a repetition of the stuttering, 
she was greatly astounded when I handed her the diet list, which consisted of 
the food already prescribed. 

Therefore, dietetic treatment also plays a role in speech disturbances that 
must be well considered. When the condition is properly understood an actual 
miracle is sometimes effected. In late years, unfortunately, the clinical obser- 
vation of children with speech disturbances has been almost entirely aban- 
doned, so that these conditions are no longer borne in mind by the clinician. 
This is owing largely to the fact that exercise treatment, which actually plays 
an important part in speech disturbances of children, and has been considered 
in another volume of this work, 1 has been forced into prominence and has been 

1 See volume on " Diseases of the Nervous System," p. 343. 



34G SPEECH DISTURBANCES OF CHILDHOOD 

left to the superintendence of empirics, teachers, quacks, governesses, and other 
persons who have not been professionally trained. This is a serious error. The 
slightest defect in articulation which arises during the period of speech develop- 
ment should be investigated by a skilled physician ; for only the reasoning phy- 
sician can properly investigate all of these individual details, the observation of 
which is so necessary if the proper results are to be attained. 



FUNCTIONAL NERVOUS DISEASES OF INFANCY 

By H. NEUMANN, Berlin 

In infancy the functional diseases of the nervous system are not merely of 
great importance on account of their extraordinary frequency ; in consequence 
of the distinctive nature of the infantile nervous system they frequently assume 
peculiar forms, and their conception in infancy is of importance in their ap- 
praisement to the extent that they usually reach their fullest development only 
in adults. 

Functional nervous disturbances cannot always be precisely defined from 
organic diseases, nor can they always be accurately systematized. From path- 
ologic states, apparently of a homogeneous nature, different groups of disease 
often develop, and in the same group the clinical picture may reveal itself in 
different forms. If we decide to consider certain signs of seemingly increased 
nerve activity only as the expression of an irritable weakness, we may make a 
schematic division by regarding some diseases as phases of a functional debility, 
others as an expression of an abnormal course. To go further, we may make a 
distinction between affections of the nervous system and mental diseases. If 
we leave the latter out of consideration, we must contrast neurasthenia with 
hysteria among the functional nervous affections. But in hysteria, particu- 
larly when its starting-point was in infancy, we often meet with conditions 
which cannot as yet be differentiated from those of neurasthenia. 

In some respects Graves' disease, epilepsy, and chorea may be regarded as 
transitions to the organic nervous affections. 

A numerical report of the occurrence of functional nervous diseases in in- 
fancy is difficult to make; the clinical material does not present itself alike 
to every observer, and many disturbances, if they are mild, are unquestionably 
overlooked. As these objections are comparatively less obvious in my dispen- 
sary practice, the following statistics are given : in the years from 1894 to 1902 
there came to my Polyclinic 1 (Dr. S. Kalischer), besides 397 organic diseases, 
741 functional neuroses and psychoses. Notwithstanding the fact that ner- 
vous diseases were also seen at other times than in the nervous clinic, there 
must be added to the former number over 1,000 cases of spasm of the glottis, 
tetany and convulsions (essentially on the basis of the latter). Therefore the 
overwhelming majority of functional neuroses in infancy belongs to the realm 

*See Fritz Schiffer, Jahrb. f. KinderhTc., 1904. The cases referred to later are not 
limited to these alone, but are also taken from private practice. 

347 



348 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

of tetanoid hyperirritability of the nervous system, that is, of simple con- 
vulsions. Next in number are conditions of mental weakness (in our statistics 
the minimum was 100), and of irritable weakness (minimum 94). The im- 
portance of the latter — neurasthenia or nervousness — becomes all the more 
apparent if we include the following groups: Headache and migraine (97 
cases), maladie des tics (23 cases). In contrast, the following diseases are far 
behind in frequency: epilepsy (118 cases), hysteria (71 cases), spasmus nutans 
(25 cases). Finally, chorea must be mentioned, with 122 cases, and Graves' 
disease, with 32 cases. The number of cases of perverse psychic development 
cannot be reckoned exactly; psychoses — more frequent after the period of in- 
fancy — came under observation only 16 times. 



CONDITIONS OF IRRITABLE WEAKNESS 

Convulsions. — First, on account of their obvious importance and exceed- 
ingly common occurrence, we shall consider the conditions of irritable weakness 
of early childhood. The best-defined and most serious manifestation of this 
weakness of cerebral function is convulsions. It is true, they are no longer 
classified as a substantive affection (eclampsia), but merely a symptom of 
disease. In another part of this work an explicit description will be given of 
these conditions. Here but a few remarks are necessary, as the convulsions 
which originate from disease of the central organs and their membranes will 
not be considered. The convulsions which occur in the course of severe 
affections, for example, cholera infantum, and which, are to be explained in a 
manner similar to uremic convulsions — as symptoms of intoxication — will also 
be omitted. I shall only refer to the tendency to convulsions which are most 
pronounced in the newborn in conformity with the undeveloped nervous system, 
and which become rare with advancing age. These are observed particularly 
in dyspeptic disturbances — from the transitory contractions due to flatulence, 
to the convulsive seizures which last for days with intervals of but a few 
minutes and which may occur even in breast-fed infants. The tendency to 
convulsions, incidentally with sudden high fever, lasts a comparatively long 
time in the infant and in the adult these are supplanted by chills. I have 
observed these febrile convulsions most frequently at the onset of croupous 
pneumonia, 1 rarely in influenza, diphtheria, parotitis or other diseases; they 
have not occurred in my practice later than the fifth year, but Henoch reports 
the condition in children of much older age. In this connection attention must 
be called to a special form of convulsions in which there is arrest of breathing. 
This apnea or " stoppage " — which is not to be confounded with spasm of the 
glottis — is most common in the second year, infrequent in the third and fourth 
years, and is probably somewhat more general in boys than in girls (8 to 5). 
Following a blow or a fall, punishment, anger, or a paroxysm of rage, there is 

1 Many of them are not the results of high temperatures, but of pneumococcus af- 
fection of the brain. The germ is mostly eliminated through the kidneys. — Editor. 



CONDITIONS OF IRRITABLE WEAKNESS 349 

an arrest of respiration, the child becomes blue and rigid, and is attacked by 
clonic convulsions; in a few moments it breathes again, either voluntarily or 
after shaking, slapping, or sprinkling with water. 

The functional nature of this entire group of convulsions is evinced by the 
absence of successive disturbances of the nervous system. As a rule they arise 
the more readily the younger the child and the greater the irritation. When 
both of these factors are considerable, possibly the neuropathic tendency, as a 
predisposing agent, may be of less importance. In many cases, for example, of 
apnea and also of febrile convulsions, it is exceedingly easy to prove not only 
the predisposition but also the presence or later development of neurasthenia 
and even of typical hysteria, and for this reason the susceptibility to convul- 
sions is mentioned at this point. 

I shall be even more brief in regard to the group of convulsions which occur 
in tetanoid hyperirritability of the nervous system and which have recently 
been much studied. Although they have a familial tendency, like the group of 
convulsions just described, the neuropathic heredity is not so distinct. They 
appear under the influence of the same deleterious factors of respiration and 
nutrition which act upon the development or exacerbation of rickets. Corre- 
spondingly they preponderate in the first half of every calendar year. 

It is immaterial whether we are dealing with an apparently substantive 
eclampsia or with spasm of the glottis, perhaps succeeded by general convul- 
sions, or whether we are dealing with the typical convulsions of tetany, the fun- 
damental structure is always an increased irritability of the nervous system 
which may readily be demonstrated by the motor and electrical tests of the 
peripheral nerves ; this condition may also remain latent — without convulsions. 
It is so extraordinarily common in infancy that, more than any other form of 
convulsions, it impresses upon the delicate age of childhood the stamp of spas- 
mophilia. 

Nodding Spasm. — A much rarer form must be mentioned, i. e., nodding 
spasm (spasmus nutans or niclitans). The principal symptoms are tremor of 
the muscles of the neck and peculiar movements of the ocular muscles ; nystag- 
mus in one or both eyes (lateral, vertical, or rotatory), with an occasional de- 
cided lateral fixation. Without entering upon a minute description of this 
remarkable affection I may state that it has no connection with tetanoid hyper- 
irritability of the nervous system. Nevertheless, its periodic appearance fol- 
lows laws similar to the other forms of spasm. Thus, among 35 cases, I 
observed 31 between December and April and only one in May, June, October 
and November respectively. Complication with rachitis is not typical, there- 
fore we may assume that the same deleterious effect of season, as in rickets, 
also favors the appearance of spasmus nutans as well as tetany. Nodding 
spasm may occur until the end of the third year. It appears most frequently 
between the sixth and eighteenth months (first six months 7 cases, second six 
months 12, eighteen months 14, two years 5, two and a half years 4, three years 
1). The preponderance of females is conspicuous (28 girls, 15 boys). 

If we disregard spasm as a definite manifestation of irritable weakness and 



350 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

attempt to describe the gross appearance of pathologic pictures, we meet with 
certain systematic complexities. Hereditary degeneration may become distinct 
in a neuropathic as well as a psychopathic sense. A congenital neuropathic 
constitution produces phenomena that may coincide largely with those of neu- 
rasthenia due to various causes, as onanism (even in childhood) ; the most 
varied phenomena of irritable weakness may be present in either case. In any 
event some of the symptoms which occasionally occur with a neuropathic de- 
generation are usually lacking in acquired neurasthenia. Further, we are con- 
cerned with typical neurasthenia which not only takes the form of nervous ex- 
haustion, but simultaneously produces a peculiar mental condition whereby the 
neurasthenic subject " is distinguished by a tendency to a constant subtle analy- 
sis of his condition, by permanent sensations of fear, and by lack of will " 1 ; in 
this sense neurasthenia of well-characterized type is comparatively rare in chil- 
dren. A differentiation of these various forms of neurasthenia has been 
found to be practically impossible. We shall therefore treat of nervousness or 
neurasthenia (used synonymously) as a great and essentially uniform patholo- 
gic group. 

This, however, does not dispose of all of the difficulties. On the contrary, 
before entering upon our theme an attempt must be made to ascertain the rela- 
tion of neurasthenia to hysteria. These conditions are very frequently com- 
bined ; as to their development, the symptoms of hysteria usually appear pro- 
gressively at a time of nervous degenerative weakness — seldom during the first 
years. In the literature we find two descriptions : Some authors set forth neu- 
rasthenic symptoms, for example, nocturnal incontinence, night terrors, as the 
tokens of neurasthenia, and infer that the hysteria appears in addition. Others 
regard these conditions as the first concealed expression of hysteria (" hysterie 
naissante " ) of St. Philippe 2 or as a distinct expression of hysteria of early 
childhood which has not yet been correctly appreciated (Bezy-Bibent, 3 Thie- 
mich. 4 ). 

It might be supposed that with a clear definition of hysteria a conclusion 
could be reached in every case, but this is extremely difficult, especially in child- 
hood. The earlier explanation of Mobius, that all of those morbid changes of 
the body which are limited to the imagination are hysterical, is inadequate even 
for the hysteria of adults, as is also the later amplification, that some of the 
hysterical symptoms are not altogether suggested but are a pathologic reaction 
to emotional agitation. Neurasthenia may also be the result of a pathologic 
reaction. We must agree with Jolly 5 that " in addition to the alteration of 
emotional and reflex excitability the psychic symptom of an increased imagina- 

ir rheodor Dunin, " Grundsatze der Behandlung der Neurasthenie und Hysterie." 
Berlin, 1902. 

2 Saint -Philippe, Art. "Hysterie; Traite des Maladies de PEnfance," Tome IV, 
Paris, 1898. 

3 " Die Hysterie im kindlichen und jugendlichen Alter." Translation by Brodtmann, 
Berlin, 1902. 

*Jahrb. f. Kinderheilkunde, N. F. VIII. 

5 Berliner kiln. Wochenschr., 1892, Nr. 34. 



CONDITIONS OF IRRITABLE WEAKNESS 351 

tive faculty " is introduced ; the " actual hysterical phenomena, a true hysteri- 
cal symptom-complex, and the entire clinical picture of hysteria, appear only 
when this effect of the imagination is combined with the symptoms arising 
from the corporeal (nervous) condition." If we agree with this view and ac- 
cordingly decide the neurasthenic or hysteric nature of a disturbance, we must 
still determine whether the diagnosis of true hysteria — we often speak of hys- 
teroid symptoms — may be made at once from the action of every abnormal 
imagination incidental to neurasthenic conditions ; for the imagination is some- 
times so greatly developed in children that there may be a transitory slight 
aberration. 

In connection with this question is a further one : Whether the success of 
suggestive therapy is such as to verify the diagnosis of hysteria in every case. 
If the part played by the imagination is so great in infancy as is generally 
recognized, if, further, the unconscious as well as the conscious psychic life can 
be influenced with comparative ease, there will be, under some circumstances, 
as the innervation of an organ, a successful regulation by suggestion, which, 
however, does not prove that the condition is hysterical. Artificial emphasis 
of a conception need not be such, even when it leads to the repair of a patholo- 
gically changed function, as to force a pathologic conception aside ; whether the 
conception acts consciously or unconsciously need not be taken into considera- 
tion. Here is an example ! The voluntary discharge of urine is inculcated in 
the child by certain external circumstances : restraint is brought about by edu- 
cation, which eventually results in an automatic reflex process. If the inhibi- 
tive apparatus is not sufficiently powerful, or if the stimulation in the urinary 
organs and the corresponding spinal reflex arc is too active, a discharge of urine 
occurs involuntarily. Under some conditions a normal condition will be 
brought about by stimulation of the will or incitement of the inhibitive appara- 
tus to greater function through a mediate influence; this stimulation may be 
psychic, as in treatment of hysteria — nevertheless, we are not dealing with 
hysteria. We would have to do with the latter affection if the evacuation were 
the result of a hysterical conception; for example, if it were thought impossible 
to control micturition under certain external conditions, recovery might be 
brought about by the removal of this idea. Therefore, the same psychic in- 
fluence might be active under various psychologic causes — by indirect strength- 
ening of the will and by the removal of the pathologic impression. The minute 
analysis of the method of cure will frequently decide whether we are dealing 
with neurasthenia or hysteria. A combination — neurohysteria — would be pres- 
ent in our illustration if, as the cause of the conception, there were an actual 
disproportion between reflex irritability of the bladder and the energy of the 
inhibitive apparatus, so that, under certain transient and local conditions, mic- 
turition could not be controlled. 

Therefore, we shall differentiate between pure neurasthenia, pure hysteria, 
and neurohysteria. 

The portrayal of the chief characteristics of the nervous child must neces- 
sarily be crude, partly because personal experience is naturally limited and the 



352 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

space is insufficient for an exhaustive exposition, and partly for the reason that 
neurasthenia would not enter into consideration if the nervous disturbance were 
a part phenomenon of some other definite disease, for example, tetany, chorea, 
or Graves' disease. 

Neurasthenia. — In infantile neurasthenia the early symptoms are those of 
an abnormally mild onset and an abnormally marked efflux of the nervous re- 
action which are covered briefly by the term " nervousness." As a rule we have 
to do with a congenital irritable weakness, therefore a careful observation will 
often show very early signs of the affection. The first symptom is an abnormal 
reaction to impressions which are transmitted by the organs of special sense 
and the sensory nerves of the skin. Furthermore, in children beyond the age 
of infancy the organs of special sense (for example, sense of smell) often 
show an excessive sensitiveness to impressions sometimes below the wave of 
normal. Even in earliest infancy sudden noises, perhaps when moderately 
loud, will produce fright and trembling, although the latter symptom is less 
common. 

With progressive inclusion of the central organ in the reflex tract the sen- 
sory stimulations and those of the special senses produce not only abnormally 
powerful reflexes but an over-active and at the same time strongly fluctuating, 
psychic irritation. Children may show a nervous predisposition by their great 
activity at play and by the conspicuous involvement of their imagination; 
pleasant or unwelcome slight incidents elicit exaggerated expressions of pleas- 
ure or of disgust. Often there is great capriciousness, with a lack of disci- 
pline this may develop into obstinacy, and a conscientious and earnest attempt 
to combat this condition gives rise to greater excitement ; the above-mentioned 
apneic attacks appear in the first years of play and are partly the result of 
anger or rage. 

The nervous child is not only active but is readily excitable, irritable, and 
sensitive, and thus a painful disturbance of the emotional equilibrium may be 
brought about by some slight external cause. The incapability of normal re- 
sponse to the influences of the outer world and of their orderly and quiet utili- 
zation often causes anxiety of mind, so that the child is shy and cries upon the 
slightest provocation. Even older children who have been deprived of their 
mental equilibrium by fright — often by some mummery or stupid joke — may 
continue in a prolonged state of terror, so that they cannot sleep in a closed 
or dark room, or without the mother's presence. More individual, constrained 
illusions of fright, partially hereditary, are also noted, as a fear of blood, of 
dogs, of worms, and the like. Sometimes a child will not stay alone in a room 
nor walk alone upon the street, will not ascend steps nor go into the cellar. 
As an example of complicated phobias I must mention the case of a boy, aged 
four years, who, frightened generally at everything new or sudden, out of doors 
was afraid of the wind, later of a storm, and would cry " Don't hurt me, wind, 
don't hurt me ! " 

The periodic relaxation of the nervous system, so necessary for normal de- 
velopment, in the nervous child is often insufficient in duration and intensity. 



CONDITIONS OF IRRITABLE WEAKNESS 353 

Next to abnormal emotional excitability disturbances of sleep belong to the 
most common symptoms. Insufficient sleep must first be mentioned: The 
child falls asleep late, less commonly it awakens too early or will lie awake 
for hours at night; it either rests quietly with open eyes, plays, "romps," or 
talks to itself or to those in the room. Young children sometimes sleep only 
when sung to, or when they are well covered and thus restricted in their move- 
ments. While the nervous infant is wakeful, the sleep of older children is 
usually disturbed, and the increasing number of illusions which are associated 
with more or less decided sensory impressions are retained even in slumber. 
The child tosses about and talks of things connected with the events of the day ; 
occasional cries, screams, or moans betray the action of unpleasant and annoy- 
ing psychic processes. 

Night Terrors. — A few words must be devoted to night terrors (pavor noc- 
turnus) although some authorities do not include this disturbance among the 
symptoms of neurasthenia. Under some circumstances there may be confusion 
with an epileptic equivalent, while the origin of night terrors from hindrance 
of nasal respiration, from worms, or from debilitating influences by no means 
precludes a neurasthenic affection; a minute examination will alwa}^s reveal 
other signs of nervousness. Night terrors are to be looked upon as a profound 
nervous disturbance of sleep. They may continue for a protracted period, or 
periodically or only occasionally. A short time, perhaps an hour, after the 
child falls asleep, it sits up suddenly, or jumps out of bed, glances around fear- 
fully, cries and screams at terrifying hallucinations, and is only gradually 
quieted, perhaps after a quarter or half an hour, by the turning on of the light, 
by talking, or by being taken into the mother's bed. A second attack may occur 
in the same night, or the sleep will be restless. Forgetfulness (amnesia) closes 
the door on these nightly occurrences. 

In my experience night terrors appear earliest in the third year of life, 
are of about equal frequency up to the tenth year, and from that time they be- 
come rare (from the third to the fifth year 9 times, sixth to tenth year 14 
times, eleventh to fourteenth year 6 times; 17 boys, 12 girls). 

We now come to the mobility of the nervous temperament. Not rarely it 
is revealed very unfavorably by a tendency to jump, flightiness, inattention, and 
may find its most conspicuous aspect in great physical unrest. The child is 
only transitorily quiet ; to use a common expression it is fidgety, " like quick- 
silver." Even when the child tries to be still, or when its attention is arrested, 
the respite is only for a few moments. This abnormality may disappear in 
time, while its increase necessitates an unfavorable prognosis as to cure, since 
alternate improvement and aggravation of the condition may persist indefi- 
nitely. In the latter case we speak of maladie des tics convulsifs, a combina- 
tion, as it were, of numerous varieties of tic, i. e., apparently voluntary, but 
actually constrained and oft-repeated movements. 

The Tics. — Often there are movements of the legs and of the lower trunk; 
but the hands are seldom quiet, they are passed over the face, the back is 
rubbed, the nose pulled, the sexual organs handled. Of greatest frequency are 
24 



354 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

movements in the musculature of the shoulder-girdle, of the nock, and of the 
face. The shoulders jerk, the head is shaken, turned or otherwise moved, the 
angle of the mouth contracts, the lips twitch, there is blinking, winking, the 
eyebrows arc raised and lowered, the forehead is wrinkled. There is snuffling, 
hawking, and in rare eases there are peculiar exultant or inarticulate sounds, 
but I have never heard the forcible utterance of obscene words such as are 
forthcoming from adults. Every patient has his individual combination of 
movements which recur for some time. These enforced movements appear 
rarely before the fifth and most frequently after the eighth year of life; the 
sexes are affected equally (in the fifth year one case, from the sixth to the tenth 
year 19 cases, from the eleventh to the fourteenth year 13 cases; 17 males, 16 
females). 

The transition to simple tic, which will not be described here in detail, is 
brought about by constrained movements, still in part physiologic, which are 
merely designated as bad habits. Sucking of the finger belongs to this cate- 
gory; in small children the skin and the nail of the finger become macerated 
and in later years the finger-tip may be calloused, the phalanx flattened, the 
nail broad and somewhat concave. While sucking of the finger is probably 
first brought about in the new-born by the accidental introduction of the finger 
into the mouth or by hunger, it finally becomes a habit, which is particularly 
indulged in just before sleep, but is practised also in sleep and at other times. 
As a rule the habit is abandoned at the school age. Biting of the nails, to- 
gether with degenerative phenomena, is much more common. 

The tendency of young children to put foreign bodies not only into the 
mouth, but occasionally also into the other natural orifices of the body, may 
develop actual disease in nervous individuals. Thus, a girl aged thirteen 
months, who presented some nervous symptoms but who was well-developed 
mentally, placed wood, pieces of candle, and the like, in the nostrils and mouth, 
ate wool and paper, and even swallowed her feces — an exceedingly rare occur- 
rence in sane children. (A proper education finally conquered the habit.) 
Another infant, after learning to creep, ate the plaster from the wall and 
swallowed many foreign bodies, and when two years old the mother pulled a 
piece of twine out of the anus. Later this child picked off and chewed wool 
from his clothes, the bed-covers and portieres ; at the age of nine years the boy 
was extremely nervous and only of average mentality. 

Certain constrained processes must be included here which commonly occur 
only in sleep, although under certain circumstances, like some involuntary 
movements of hysteria, they are observed during complete consciousness. 
Transition to these also may occur from movements yet within the scope of the 
norm. Many children will fall asleep only when their finger or a portion of 
the bedding is in their mouth, when the bed-clothes are drawn over the face, 
when they are uncovered, or when they are sitting, or lying upon the belly. 
Close to the norm also is the habit of some children of gritting the teeth; its 
sudden appearance, however, arouses a fear of disease of the brain. Cough 
during sleep every night at a certain time is not uncommon and is sometimes 



CONDITIONS OF IRRITABLE WEAKNESS 

associated with retching and vomiting which naturally awakens the child. The 
fact that cough is absent while the child is awake and can be overcome by sng- 
gestion indicates its nervous nature. 1 Automatic movements in sleep are 
various ; they are usually noted in children with grave hereditary degeneration. 
I saw a girl aged nineteen months who almost every night, before midnight, 
began to kick and scream. Later the child suffered from pseudo-croup, her 
sister from hystero-epilepsy ; subsequent to my visit the condition disappeared 
suddenly, after a continuation of nearly six months. A girl somewhat older 
chewed and swallowed in her sleep and executed rhythmical movements with 
her elbows. Other children sleep for hours upon their belly, with the head 
pressed against the pillow, and perform rocking movements with the trunk 
which are at times so severe as to shake the bed. 

The classification into a particular system of disease of the dream actions 
which we observe in children may sometimes be exceedingly difficult. Children 
with vivid imagination have hallucinations in sleep in which they continue 
their play. Other children speak in their dreams of school or of the occur- 
rences of the day. They may even rise and perform complicated movements, 
such as packing their school-books. Complicated somnambulistic processes 
lead from the realm of neurasthenia to hysteria. 

Onanism. — In conclusion, onanism must be described: this is legitimate in 
so far as it is an impulsive action of nervous children. Onanism in older, 
normal children, which is the result of the example or was taught by servants, 
rarely comes to the notice of the physician. In the worst cases, as already 
mentioned, it may lead to severe neurasthenic exhaustion. t 

Onanism is practised equally by both sexes. My statistics show, during the 
first five years. 6 boys and 9 girls; from the sixth to the tenth year. 10 boys 
and 11 girls: from the eleventh to the thirteenth year, 4 boys and 2 girli 
total of 20 boys and 22 girls. The beginning of the vice may often be t: 
to early childhood (in T2 of my cases the habit began in at least IS instances 
in the first five years). In the first two years onanism appears to be more 
common in girls (among 9 children of this age 6 were females) — a fact 
already mentioned by Hirschsprung. 2 In little girls onanism is often over- 
looked : the child, in my experience, at the earliest six months old. suffers from 
peculiar attacks in which the legs are pressed tightly together, or more rarely 
are crossed, and the hands are sometimes folded: there is pressing, squeezing, 
and groaning, the face is flushed, and there is an outbreak of perspiration. 
The act of masturbation cannot always be interrupted even by raising the child, 
from the recumbent posture. One of my cases, a girl aged 9 months, drew 
herself toward the bed-post and, with pressure and groans, stamped with her 
legs. Older children perform swaying movements while seated, sometimes ac- 
companied by singing. Occasionally they slide along the floor, or lie upon 
the abdomen and perform rubbing motions. In children of still greater age 

l A cough appearing after sleeping demands the examination of the throat I chronic 
catarrh, large tonsils, long uvula). — Edh 
'•Berliner Win. Wochensekr, 1886. Nr. 38 



350 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

the movements are definite, especially friction upon the genital organs with the 
hands. 

I need not dwell upon the persistence of onanism at every period of the 
day. Masturbation is practised at night in half sleep as well as while awake. 
There are sexual equivalents for onanism in children of one to two years who, 
after weaning, suck their fingers, pieces of linen or the bed-clothes, not infre- 
quently, as Steine 1 reports, " with simultaneous erection, marked flushing of 
the face, unusual brightness of the eyes and, finally, with an outbreak of perspi- 
ration." This most commonly occurs while falling asleep or shortly before 
awakening. The same symptoms are noted in nurslings. I learned that for 
three years a patient of mine, a boy aged 10 years, had sensations of lust when 
he watched flowing water or snakes in motion, and that while dreaming of simi- 
lar things in his sleep he would lie upon his abdomen and involuntarily produce 
friction. Such indefinite sexual irritations — especially in sleep — are so com- 
mon during pubescence that they can then scarcely be regarded as pathologic. 

The consequences of persistent onanism in young children are comparatively 
insignificant, and consist mainly of exaggerated irritability which may result 
in attacks of mania. Older children who are addicted to this vice are shy, dis- 
agreeable, sullen, downhearted and stubborn; they are slow to learn, are lan- 
guid, have dark circles around the eyes, and complain of palpitation. The 
patellar reflex is active, the penis is readily erected; various nervous disturb- 
ances, such as the tics may also the present. Irritation in the vicinity of the 
sexual organs may be the cause of masturbation, such as oxyuris, or chronic 
eczema of the genitalia and of the thighs, which produce pruritis. Accidental 
pressure during the discharge of urine and feces may be a first cause and per- 
haps explain the more frequent occurrence of masturbation in little girls. The 
prognosis is least favorable when onanism is practised by small children in the 
absence of a recognizable cause. 

The foregoing deals in the main with the abnormal development of the 
psychic life of the nervous child under the influence of the external world; 
more difficult is the description of the uncommonly diverse influences exer- 
cised upon the nervous system by the sensations which originate from the dif- 
ferent organs of the body. Briefly stated, the sensations arising in various di- 
rections from a pathologic condition may produce abnormal impressions upon 
the sensory sphere, and, under certain circumstances, influence the will and 
conception unconsciously, so that transitions to hysteria arise; furthermore, 
the reflex processes of muscular and vasomotor nature are variously influenced 
abnormally. The appreciation of these conditions is rendered difficult because 
we simultaneously have to deal with disease of a peripheral organ (under some 
circumstances of the brain itself), and a central nerve which reacts patho- 
logically, and a correct estimate of the part played by each component cannot 
always be made at once. 

The nervous child may have, from insignificant causes, for example, dis- 

1 " Compend. der Kinderkrankheiten,' 



CONDITIONS OF IRRITABLE WEAKNESS 357 

turbances in the digestive tract — attacks of screaming which are unusual in 
their severity and duration and make those about him almost frantic; under 
some circumstances they may lead to reflex convulsions. On the other hand, 
severe debilitant conditions may occur without serious organic disease. I re- 
member the case of a child, aged five months, who had periodic attacks of 
" insane " screaming, particularly at night, and, as I convinced myself, could 
scarcely be appeased after some trifling annoyance, but when nursed it suc- 
cumbed • " with lusterless eyes." The feeling of weakness, of lassitude, occa- 
sionally associated with somnolence and early fatigue w^hen at play, and 
especially during stud} r , is particularly common at the school age, and is then 
maintained by the various causes of neurasthenia (school, disease) which will 
be considered in detail later. This may be associated with a melancholy or 
peevish disposition, perhaps characterized by frequent sighs or thoughts of 
death ; sensations of syncope are unusual but vertigo is common. 

Vertigo. — In many children the sensation of vertigo appears after great 
activity of movement, therefore, they cannot endure to ride in a carriage or 
upon electric or steam railroads. This symptom is often accompanied by 
vomiting. I do not know whether such children are especially subject to ver- 
tigo when looking from a height, or to seasickness. 

Headache and Migraine. — Headache is extraordinarily common in the 
nervous individual and must be discussed somewhat more in detail. Although 
it is probably due most often to vasomotor disturbances, its nature is by no 
means clear. Migraine — that form of headache which appears periodically — 
is not rare in infancy, although customarily it appears much later. T do not 
altogether concur in Oppenheim's statement 1 that the usual development of the 
affection is at puberty. In 9 of my 43 cases it began between the second and 
fifth years (once in the second and once in the third year), in 21 cases between 
the sixth and tenth years (10 times after entrance at school), and in 13 cases 
between the eleventh and fifteenth years. Neither do my figures correspond 
with Oppenheim's report as to sex, namely, that females are more frequently 
affected; possibly after childhood (with which only we are concerned) the 
sexual life of woman is more productive of migraine. Among my 43 cases 27 
occurred in males and only 16 in females. In the first five years of life both 
sexes are equally affected (5 males, 4 females). From the sixth to the tenth 
year the male sex predominates (14 males, 7 females). From the eleventh 
to the fifteenth year the proportion was 8 boys to 5 girls; therefore, notwith- 
standing their dawning maturity, females are not in the majority even at this 
age. 

Migraine is a typical example of homologous heredity, scarcely equalled 
by any other nervous disease. Only 5 of my 43 cases were lacking in this 
respect. In 26 cases (therefore 60 per cent.) the mother suffered from mi- 
graine, in 16 instances the father, both parents in 3 cases, and 3 times other 
ancestors. In some instances brothers and sisters or several members of the 

lf 'Lehrbuch der Nervenkrankheiten," 1902, 3 Aufl., p. 1010 



358 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

family suffered from the malady. The well-known typical symptom-complex 
is usually present even in childhood. As a rule, the headache is localized in 
the frontal region; rarely, as I found in coincidence with Henoch, is there a 
well-developed unilateral affection. Pain is seldom present in the occiput; 
vertigo, nausea, and vomiting are usual. The attack terminates in sleep, from 
which the child awakens well. The duration and frequency vary as greatly 
as in later life. As a rule the cases are of the angiospastic type of migraine, 
with marked pallor ; rarely there is an alternation between pallor and flushing. 
Sweating is common. The eyes are seldom involved (usually flittering sco- 
toma or loss of vision) ; a hypersensitiveness to noises is noted. There may 
also be simultaneous abdominal pains with frequent evacuation of urine and 
feces. Under rare circumstances a trigeminal neuralgia may replace the head- 
ache; the attacks are sometimes incomplete or may pass into a more or less 
continuous headache. In quite a number of children who suffer from migraine 
nervous symptoms are demonstrable; while many of them may show fair mental 
development, others are distrait and of poor mentality. An outbreak of mi- 
graine is often brought about by attendance at school (conspicuously often in 
boys ! ) . Often during the holidays there is a cessation of the attacks. 

Nervous Headache. — No less important than migraine is simple nervous 
headache (53 cases, as opposed to 43 cases of migraine). It is rarely paroxys- 
mal but continues for hours or days or through the night. Occasionally it 
is associated with vomiting or vertigo. As a rule it is due not only to mental 
or emotional exertion but to other causes as well. This form of headache, like 
typical migraine, frequently begins in early school life, and from that time 
it increases, but is generally absent when the child does not attend school, as 
during the holidays. Stud}', writing, singing and gymnastics are sometimes 
mentioned as etiologic. The pain is increased by heat, running, and the like. 
The affection may occasionally influence the power of thought and memory. 
While the factors just mentioned are capable of producing the affection, other 
causes are injury to the head, inflammation of the brain, and infectious dis- 
ease, as scarlet fever. A conspicuous cause is disease of the ear. On the other 
hand, this form of headache frequently occurs in children with the most varied 
neurasthenic symptoms; in particular a large number of such children are of 
feeble mentality and therefore are not equal to the requirements of school, 
and another very large group are afflicted physically, above all scrofulous. 

Sanger 1 calls attention to a form of headache which is usually localized in 
the frontal region above the eye-brows and is to be regarded as an additional 
symptom of nervous asthenopia. I have little knowledge of it. 

The distribution differs as to age and sex from that of migraine; in the 
first five years 2 4 children (the youngest two years old, 2 males, 2 females), 
from the sixth to the tenth year 16 children (7 males, 9 females), from the 
eleventh to the fifteenth year 32 children (20 girls, 12 boys: explained, per- 
haps, by pubescence and chlorosis). 

1 Neurasthenie und Hysterie bei Kindern." Berlin, 1902. 

2 Time of observation. 



CONDITIONS OF IRRITABLE WEAKNESS 359 

Gastric Colic. — In children nervous "gastric colic" is much less common 
than " head colic" The condition should only be considered as the cause of 
abdominal pain after careful investigation has excluded all organic affections. 
As a matter of fact when there is no attack the examination of the abdomen does 
not elicit pain. Occasionally the intestines may be palpated as narrow, tightly 
contracted strands and the abdominal aorta is felt to pulsate with unusual 
force. The attacks are most frequent at night. The severe abdominal pains 
(usually in the region of the scrobiculus cordis) are associated with nausea 
and vomiting ; the child cries or whimpers, the legs are drawn up, and pressure 
is made upon the abdomen. Heat and particularly pressure and friction over 
the belly ameliorate the condition; the ingestion of food results in some cases 
in a renewed attack. In the intervals between the seizures the appetite does 
not appear to be disturbed. I have observed these colics mostly between the 
sixth and tenth year of life and somewhat more frequently in girls. Upon 
careful inspection other nervous symptoms will be found. 

Attacks of head and abdominal colic, indicating an extensive vasomotor 
disturbance of innervation, are rare. A pale, nervous girl, aged 12, who had 
a small goiter, suffered for a year from head and abdominal colic, with syncope 
and chilliness, in which the face was pale, the hands cold, and there was for- 
mication ; after a duration of about an hour the attacks gradually subsided. 

local Asphyxia. — Certain varieties of local asphyxia must be mentioned, 
as well as the secretory disturbances which are especially distinguished by 
local or general sweating. (Other forms of asphyxia, for instance, when they 
are associated with paroxysmal hemoglobinuria, are to be referred to syphilis.) 

Bronchial Asthma. — At this point, contrary to general custom, bronchial 
asthma will be considered. It may readily be differentiated from hysterical, 
cardiac, and uremic asthma. An infectious catarrh of the respiratory pas- 
sages, whether it be true influenza or some other infection, not only produces 
a gradual swelling of the mucosa but simultaneously a spasm of the smooth 
muscles of respiration. The catarrh may have been acquired recently by con- 
tagion — as is usually demonstrable — or may be of long standing and flare up 
when opportunity offers; the recent catarrhs are productive of asthma, espe- 
cially in the cold seasons of the year. With marked involvement of the larynx 
the symptoms-complex of pseudo-croup is developed, but if the deeper respira- 
tory passages are involved the clinical picture is that of asthma. The latter 
condition need not be especially described here ; nevertheless it should be men- 
tioned that while the adult gasps for breath in the sitting posture during the 
attack, the little child may lie upon the abdomen or upon the side. Asthma, 
like pseudo-croup, commonly occurs at night. After the nervous outbreak is 
past a catarrhal condition of the respiratory passages becomes prominent and 
runs its course with or without complications. Boys are more often affected 
than girls (in the proportion of 16 to 11). The initial attack is often in the 
first years of life. In so far as its onset could be determined, among 28 cases 
asthma began 17 times in the first five years, and of these, 5 times in the first 
and 3 times in the second year. Careful investigation will always disclose a 



360 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

nervous predisposition; occasionally there is a directly homologous heredity. 
Just as in many families migraine is prevalent, so also is asthma. The chil- 
dren show the symptoms of neurasthenia in the most varied combinations; not 
infrequently they suffer from urticaria or from chronic eczema. 

Whereas asthma may be referred to an abnormal reaction of the smooth 
musculature, in nervous vomiting and nocturnal enuresis there is a combined 
action of the voluntary and involuntary muscles. In contrast to asthma, both 
of these symptoms belong to the most common manifestations of infantile 
neurasthenia. 

The ingestion of food by the normal infant is often frustrated by psychical 
influences; the child is disturbed in nursing by anything that may divert at- 
tention — playthings, noises, strange people. The change from fluid to solid 
food is very difficult to accomplish. Special preferences in taste are also 
noticeable ; food that is not desired or that is forced upon the child is vomited. 
In the nervous subject these conditions are often developed to a pathologic 
degree. In certain cases drinking is hindered by the child's activity ; there is 
great disinclination for solid food, and slowness in chewing and swallowing. 
A bolus of food may be kept in the pouch of the cheek for several hours. A 
single meal occupies hours and still is insufficient. Deglutition, provided it 
occurs at all, it brought about by retching, and is succeeded by vomiting. As 
every variety and degree of difficult nutrition may be due to nervous influences 
a judgment of the actual condition is not always easy. In addition is the pos- 
sibility that the transition from nervous anorexia to a fundamental disturb- 
ance may be unnoticed. According to Pawlow's investigations the secretion 
of gastric juice is goverened essentially by psychic influences, by the desire for 
food. Therefore in physiologic gastric digestion there is a psychic element 
which may be opposed by a disturbance of the central nervous apparatus as 
well as by defects in the digestive canal. A participation by both com- 
ponents is probably not rare, although which of them is the first to suffer func- 
tionally cannot always be determined. 

The repugnance to food and the subsequent vomiting can more readily be 
judged aright if they have to do only with certain articles of diet, and after 
they are vomited the child ingests the remainder of the meal without difficulty. 
Emesis of this sort occurs readily in children; even the sight or smell of some- 
thing obnoxious will give rise to it. 

Every conception which is associated with marked emotion is liable to pro- 
duce vomiting in a nervous child. It is well known that such children vomit 
in the morning before going to school, but never on holidays nor during the 
vacation. When breakfast is eaten without appetite and in insufficient quan- 
tity the food which has been forced into the stomach may readily be the original 
cause of emesis. This occurs after breakfast, usually on the way to school, 
rarely in the school-room, without any special after-effect. From this condi- 
tion there are transitional processes to hysteria, but true hysterical disturb- 
ances of the digestive canal will be considered later. 

Enuresis. — The voluntary retention or evacuation of urine is a complicated 



CONDITIONS OF IRRITABLE WEAKNESS 301 

act of the will; not until toward the end of the first, and often in the course of 
the second year of life, does the child learn to control this function, and in 
those whose physical growth has been retarded — to say nothing of the chil- 
dren who have not developed mentally — a longer time may elapse. Just as the 
static functions which have been acquired latest are forgotten after debilitating 
diseases may the control of micturition in early infancy be again lost through an 
enervation of the nervous system — therefore, after any somatic affection or 
from excessive psychic irritation, for example, a residence at the seaside. In 
nervous children also the simple diversion of play, any excitement, fear or sud- 
den fright, may result in an involuntary discharge of urine, and, exceptionally, 
also of the feces. Even slight distension of the bladder will incite an involun- 
tary discharge, either through an insufficient innervation of the sphincter 
vesicae or an abnormal reflex stimulation of the detrusor muscle; the latter 
cause is indicated by the spastic condition (with increased patellar reflexes) 
which is often demonstrable in the lower extremities. Furthermore, the irri- 
table bladder causes frequent voluntary evacuation, sometimes every few min- 
utes (pollakiuria) ; if this act is not performed at once the urine is ejected 
voluntarily. Very often this accident occurs without any attempt to control. 
In rare instances the involuntary expulsion is not periodic but occurs as a con- 
stant dribbling. In the majority of cases, in addition to enuresis, diurna, or 
pollakiuria, there is nocturnal evacuation (enuresis nocturna) ; less often the 
latter condition alone is present. In favorable cases enuresis nocturna may be 
prevented by awakening the child for the voidance of urine, particularly when 
the expulsion can be expected at a definite time after the child falls asleep. 

From this explanation it is evident that involuntary micturition occurs 
most commonly after the second year, i. e., between the third and fifth years, 
and after that period is gradually overcome. Males are more often affected, 
at least in infancy. I have observed 25 cases of enuresis between the second 
and fifth years (14 males, 11 females), 19 cases between the sixth and tenth 
years (15 males, 4 females), 5 cases between the eleventh and fourteenth 
years (2 males, 3 females) — a total of 31 boys and 18 girls. 

Careful investigation, at least in older children, may disclose other neu- 
rasthenic phenomena of varying degrees. If this evidence cannot be obtained 
we must determine whether the enuresis is due to other nervous affections 
(idiocy, paralysis) or to local causes (catarrh of the bladder, calculus, etc.). 

Various localized neuroses might be included here, such as writer's cramp. 
Stuttering is of special importance, but a comprehensive description of the con- 
dition may be omitted. 

Having described the individual symptoms of pure infantile neurasthenia, 
an attempt must be made to classify them according to the age at which they 
appear. In the first, but more frequently in the second, year great nervous 
irritability becomes conspicuous (abnormally active reflexes from sensory im- 
pressions) ; the onset is gradual even in the emotional sphere. Active bodily 
or psychic irritation is followed by reflex general convulsions. In certain 
organs there is an abnormal reflex excitability of the involuntary muscles : in- 



362 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

spiratory arrest, asthma and pseudo-croup, enuresis. On account of the im- 
portance which the absorption of food assumes at this age nervous disturbances 
are very liable to arise: nervous anorexia, vomiting. Nervous girls tend to 
onanism. From the sixth to the tenth year the school life begins — so import- 
ant an event to nervous activity ; at this period the frequency of infantile dis- 
eases, with their debilitating influences, increases. The neurasthenia now 
reaches its acme; the emotional and intellectual tension enforces an activity 
which often leads to physical unrest, sometimes to compulsory movements 
(maladie des tics convulsifs) . Even in sleep this unrest continues and occa- 
sionally causes night terrors. Enuresis decreases somewhat, onanism becomes 
more frequent. Some children are unequal to this increased exertion; they 
become tired and debilitated, headache or migraine appears. In the following 
lustrum (eleventh to the fifteenth year; as a rule, in our observations the last 
year is not included) there is a certain retrogression of the individual nervous 
phenomena except that in girls the headache increases — probably in conse- 
quence of the deleterious influence of development (chlorosis). 

Notwithstanding the fact that in the first years of life the male sex is more 
liable to neurasthenia, a complete summary shows that, if we exclude neuro- 
hysteria, males and females are affected in nearly equal ratio (in our dispen- 
sary service 80 boys, 86 girls). 

The causes of neurasthenia will be considered in detail in the treatment. 
Neurasthenic symptoms appear in conjunction with various diseases of the 
nervous system, and in particular after meningitis, encephalitis, and in degen- 
erates or feeble-minded children; they are also quite usual after chorea and 
epilepsy. The occurrence of neurasthenic phenomena following exophthalmic 
goiter (Graves' or Basedow's disease) will be discussed later. 



HYSTERIA 

Hysteria. — Of special interest and by no means rare, as was explained in 
the introduction, is the combination of hysteria with neurasthenia, either by 
the presence of unrecognized hysterical phenomena with the neurasthenia, or 
by the association of neurasthenic symptoms with well-developed hysteria. 

Accordingly, many authors make no distinction between hysteria and neu- 
rasthenia and the reports relative to the distribution of hysteria, to the individ- 
ual age, and to sex, are widely diverse. Nevertheless most authors, myself 
included, agree that hysteria is comparatively rare before the seventh year and 
that from this age females are preeminently affected. My compilations, which 
cover several years, show that of 64 cases 48 occurred in females and 16 in 
males: in the fourth and fifth years one boy, 2 girls; from the sixth to the 
tenth year 9 boys, 11 girls; from the eleventh to the fifteenth year 6 boys, 35 
girls; or, with a different arrangement, from the fourth to the eighth year 8 
boys, 4 girls ; from the ninth to the fifteenth year 8 boys, 45 girls. 

This preference for the female sex must not lead to the assumption that 



HYSTERIA ' 363 

sexual processes of an immediate nature instigate an outbreak of hysteria, 
although occasionally they may act as psychic traumata; on the contrary, the 
peculiar physiologic effect of feminine maturity upon the psychic development 
favors the mediate cause of hysteria, so that, as a rule, the slumbering heredi- 
tary predisposition 1 to hysteria becomes manifest at this time. I shall dwell 
briefly on the nature of this affection, as it does not differ essentially from the 
hysteria of adults. The psychic character of the disease is acknowledged (I 
refer to my previous explanation, page 350). There is a peculiar change in 
the hysterical imagination, in which certain associated ideas, normally of a 
transient nature, are unconsciously retained and distorted until they give rise 
to morbid psychic or somatic phenomena. When physical sensations are the 
object of conception, as generally is the case, they are constantly and uncon- 
sciously absorbed in the conception; for example, pain is felt and expressed 
as abnormally severe, or is still further elaborated by the child in accordance 
with its lay impression of the human body. Imagination or autosuggestion 
in children predominates in the motor sphere, less often in the sensory sphere, 
of the region in question; therefore, upon an ideogenic basis, convulsions and 
paralysis, over-sensitiveness, to pain, or pain paralysis, arise. Besides, the 
association of ideas which occurs under the wave of consciousness need not 
always be in excess of this impulse, so that often the patient is not particu- 
larly aware of the anesthesias and analgesias. In so far as the associated un- 
conscious chain of perception cannot at all, or only with the greatest difficulty, 
be severed by conceptions consciously opposed, we speak of hysterial feebleness 
of will — an expression which may readily give rise to a false interpretation of 
the psychic mechanism. 

The origin of the hysterical manifestations may be widely diverse. An 
accidental constellation of ideas may produce hysterical phenomena which, 
under some circumstances, appear in a dream, while the control of conscious- 
ness is lost; or an external factor — an exciting discussion, hygienic instruction 
at school, watching or listening to the complaints of a sick person may produce 
such a strong corresponding impression that between the reception of the idea 
and its hysterical development some time will elapse. 

Furthermore, by an accidental association of ideas, normal sensation may 
force an abnormal hysterical conception, or morbid corporeal processes in imme- 
diate or mediate sequence may result in a hysterical manifestation; for ex- 
ample, pain may lead at once to a markedly disproportionate reaction — paraly- 
sis, syncope, spasms of screaming or other convulsions — or after a disappear- 
ance of the actual lesion the corresponding impression of pain, or an associated 
reaction, may continue or be subsequently revived. In so far as we are con- 
cerned with an active accentuation of pain or sensations of exhaustion (with- 
out other sequels) a differentiation between hysteria and neurasthenia may be 



1 In the dispensary a nervous predisposition could be determined only in one-third 
to one-fourth of the cases, but the investigations in this direction do not appear to me 
to be conclusive. 



364 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

difficult or even impossible. The mental condition and the psychic habitus 
must then be invoked as aids in the diagnosis. 

The hysterical psychic component may be expected as a regular accompani- 
ment of hysteria even to a less extent in the child than in the adult. Never- 
theless, in girls, particularly those of older age, we find the well-known insta- 
bility and superficiality of the emotions, occasionally a remarkable precocity 
and loquacity, and a coquetting with events of a personal nature. Their de- 
scription of their respective troubles is exaggerated and verbose but quite un- 
emotional. Their thoughts are concerned not only with their physical state but 
also with other matters. Just as with adults will the hysterical child, directly 
or upon suggestion, tell the most ridiculous or even cunning falsehoods uncon- 
cernedly and without the slightest hesitation. The morbid mental condition is 
indicated — often from earliest childhood — by the hysterical glance. Rarely 
have I observed hysterical insanity in older girls. 

Head's Zones. — As regards the character of neurasthenia and hysteria and 
the relation of the two diseases, the study of hyperesthesia is very instructive. 
In the neurasthenic debility of the nervous system, with stimulation in the 
course of a nerve segment, there is often a distribution of the irritation within 
the transverse section, so that pain develops in the corresponding cutaneous 
area, either spontaneously or by contact. These cutaneous zones, and in par- 
ticular the conspicuous points of pain, have been closely studied by Head. 1 
Quite commonly they are to be found in infancy, in their ordinary distribution, 
in congenital neurasthenia or in acute neurasthenic conditions (for example, 
after influenza), and on account of the frequent combination of neurasthenia 
and hysteria they are also not rare in the latter affection; they may then be 
expressed in an exaggerated hysterical manner, but, although attention may be 
diverted from them, as from pain, they cannot be made to disappear by sugges- 
tion. " Head's zones " may appear in the neurasthenic subject after the slight- 
est, sometimes physiologic, stimulation. For example, they are not rare in cir- 
cumscribed areas of the skin over the maturing female breast or over portions 
of the intestine distended by fecal impaction, and are often demonstrated upon 
the chest and abdomen without a recognizable cause. Naturally, they are quite 
as frequent in pathologic stimulation of the organs, for example, over the 
stomach after it has been irritated by vomiting or otherwise. That these zones 
appear in hysteria without simultaneous neurasthenia seems to me doubtful. 
Certainly they should not be regarded as a sign pathognomonic of hysteria, as 
is still quite usual. The hyperesthesias typical of hysteria, such as hypersensi- 
tiveness of the entire cutaneous surface, like the hysterogenic pressure points 
(ovarialgia), are not common in childhood. 

The circumscribed anesthesias and analgesias — particularly upon the ex- 
tremities in the well-known cuff -like limitation — are also rare. Hypalgesia 
or analgesia distributed over the entire cutaneous surface or limited to one- 

ia Die Sensibilitatsstorungen der Haut bei Visceralerkrankungen." Translation by 
Wilhelm Seiffer. August Hirscnwald, Berlin, 1898. 



HYSTERIA 3G5 

half of the body (also with involvement of the organs of special sense) is some- 
what more common. 

Although the stigma of psychic and sensory nature are often disappointing 
in infantile hysteria, their manifestations are less complex than in the adult. 
We might therefore speak of a monosymptomatic form of hysteria. The diag- 
nostic difficulties are occasionally great, provided there is no suspicion of a 
nervous affection. Frequently, with the simplicity of the complaint, the fool- 
ishness of the underlying conception is an aid to the physician. 

Most often we meet with seizures: These are often introduced by pain, 
subjective twitchings and tremors, cardiac palpitation, dyspnea, or flushes of 
heat. Then, as a rule, with the sensation of vertigo, the child is attacked with 
syncope, in which condition it remains for a varying number of minutes; 
consciousness usually is more or less retained, but in rare cases is altogether 
lost. The attacks generally occur in the presence of others — preferably in 
school, occasionally upon the street — and without injury to the body. From 
this there are transitions to severe hysterical spasms and convulsions, but 
rarely, among German children at least, to the hysterical stupor and somnam- 
bulism or the great hysterical seizures which have been carefully studied by the 
Charcot school. 

Naturally, it is impossible to discuss all of the various expressions of the 
hysterical imagination, but some of the more common forms must be briefly 
mentioned. Often there is a complaint of twitching in various parts of the 
body at a definite or indefinite time, or from some particular cause. From 
these, in older children, tics or localized spasms arise. Occasionally one or 
another extremity becomes rigid or performs apparently involuntary, definite 
movements, or, in consequence of unconscious, more or less close imitation, 
some pathologic phenomena are presented. Even young children not infre- 
quently declare that a certain portion of their body, in which, transitorily, there 
has been an unpleasant or painful sensation, cannot be moved ; therefore, that 
they cannot rotate the head, cannot sit erect, cannot stand nor walk (astasia 
abasia). While the recognition of this pseudoparalysis is not difficult, the hys- 
terical pain which continues in the youthful imagination after a fleeting period 
of reality, and produces a corresponding imitation of movement, atrophy, etc., 
may not be properly appreciated for a long time. 

No less common, and under some circumstances difficult to estimate, are 
the pains which simulate disease of the internal organs and are due to a memory 
of former pain or to an active imitative sensation. In children these sensa- 
tions are mostly in the head and stomach. 

Besides the vertigo and pain phenomena, quite often there are disturbances 
in the respiratory, digestive, and urinary passages. Symptoms relating to the 
special senses, and vasomotor and secretory disturbances, are rare, at least in 
my experience. Thus, we meet with cough, hoarseness, sobbing, and especially 
asthmatic complaints of hysterical nature in which autosuggestion or uncon- 
scious imitation plays a part. Further, there is retching, eructation, vomiting, 
inability to eat or digest certain foods, and at last a general disinclination for 



36G FUNCTIONAL NERVOUS DISEASES OF INFANCY 

nourishment. To avoid confusion I shall describe hysterical vomiting, which is 
so common, and contrast it with the also common neurasthenic vomiting. The 
latter condition is an easily induced reflex which cannot be suppressed on ac- 
count of nervous weakness and is due to the eating or thought of something 
obnoxious. In the former condition the subconscious memory of an act of 
vomiting, which was observed in another person or performed by the hysterical 
child itself, is afterwards translated into the corresponding muscular action by 
an abnormally vivid conception image, therefore upon attempts to partake of 
food. Thus, a child, whose grandmother suffered from emesis due to carcinoma 
of the stomach, vomited after any excitement ; another child who first vomited 
after a dose of medicine, subsequently repeated the act after each attempt to 
take food. Under some circumstances, however, neurasthenic vomiting cannot 
be differentiated from the hysterical form. 

With difficult defecation the circumstances are quite similar : Through an 
insufficient control of the will habit constipation often develops, either in con- 
sequence of a weakening of the spontaneous stimulation of evacuation by fre- 
quent artificial aid, or because the nervously active and flighty child does not 
give sufficient attention and effort to the stimulus which arises. In the former 
case, as Thiemich x rightly emphasizes, a cure can be accomplished by the with- 
drawal of all treatment, but I hesitate, in the one case as in the other, to deduce 
a diagnosis of hysteria from the successful stimulation of the will. On the 
other hand, it is not to be denied that the hysterical idea of not being able to 
defecate can lead to habitual constipation. I saw hysterical constipation, as a 
consequence of disgust, in two young boys. " It is dreadful to have a move- 
ment of the bowels " was the statement of a boy aged three who never had a 
desire to defecate when reminded of it, except at night, at which time the in- 
hibitive conception was less strong and he therefore called when there was an 
inclination for stool. During the day, instead of the perpetual constipation ob- 
served in another case, he voided feces and urine into his trousers. 

Involuntary passage of urine may be either of a neurasthenic or hysterical 
nature. I assume the latter to be the case if, as already mentioned, at an in- 
auspicious moment there is an irresistible impulse to urinate and the concep- 
tion is at once translated into the act. 

As little as it is possible generally to construe all of the modes of manifes- 
tation of hysteria in advance, just as little is this possible in infantile hysteria. 
Not only are functional diseases simulated in hysteria, but under some circum- 
stances, through a hysterical disturbance of innervation, they may actually 
exist. For example, it is presumed that the stomach is not capable of digesting 
mild food, whereas the immoderate introduction of all kinds of food, and even 
that difficult to digest, shows that the organ can functionate normally. Cer- 
tain spastic conditions of the muscles of the stomach, which lead to gastrec- 
tasis and its sequels, possibly belong to this category. 

Diagnosis. — In the diagnosis of functional neurosis (as always in the exam- 

1 Jahrluch fur Kinderlieillcunde , N. F., VIII, p. 886. 



TREATMENT OF NEURASTHENIA AND HYSTERIA 3G7 

ination of children), it is primarily advisable to lead the patient into conversa- 
tion. This permits an insight into the mental condition. The behavior of the 
child, its emotions and intelligence, and especially the nature of its complaints 
and the manner in which they are described, as a rule will readily indicate that 
we are not concerned with a pure somatic disease; hence we investigate the 
nervous phenomena, of which there is no special complaint. Associated with 
this is the physical examination, the importance of which in infancy cannot be 
emphasized too greatly, since confusion with organic diseases — even of the ner- 
vous system — may readily occur. All of % the aids of diagnosis — ophthalmo- 
scope, X-rays, etc. — are to be invoked. The beginning of a brain tumor, car- 
diac insufficiency, albuminuria, or neuphritis may readily be overlooked ! On 
the other hand, it is scarcely necessary to mention that a functional neurosis 
may have for its sequel an organic disease ; for example, nocturnal enuresis, an 
inflammation of the bladder; neurasthenic debility, brought about perhaps by 
onanism, an insufficient activity of the heart. Here again we must mention 
that a substantive organic affection (as an injury) may appear under the guise 
of a neurosis. If it has been determined conclusively that the child is suffering 
from a neurosis, it is important for the diagnosis, prognosis, and treatment to 
understand clearly the importance of heredity, social and educational factors, 
and, for the treatment of the individual symptoms, the opportunity for psychic 
contagion. Finally, the investigation of the case must lead to a differentiation 
between hysteria and neurasthenia. Not infrequently the diagnosis only be- 
comes positive after the success of the treatment has been manifested. 



TREATMENT OF NEURASTHENIA AND HYSTERIA 

As the treatment of neurasthenia and of hysteria has much in common, 
and there are but few factors in opposition, to save repetition these two affec- 
tions will be considered together. While the abnormal predisposition cannot 
be removed, and the symptoms dependent upon it frequently cannot be dis- 
pelled for internal or accidental external reasons, nevertheless our therapeutic 
efforts, in these nervous affections which may seriously and permanently impli- 
cate the welfare of the patient and his enjoyment of life, are not to be under- 
valued, since it is most easy to attack the root of the evil in infancy. First we 
shall concern ourselves with the neurasthenic and hysterical conceptions, and 
afterwards with the individual symptoms to which they give rise. Barely in 
hysteria, but more commonly in neurohysteria and in pure neurasthenia, the 
general condition of health is below the normal, and its improvement is a pre- 
requisite in the cure of the nervous affection. In so far as we are concerned 
with an acute cause in the outbreak of neurasthenia, the diseases of infancy 
are operative among the somatic factors, and perhaps quite as frequently acute 
catarrh of the respiratory passages, which is mostly the result of influenza. 
Among the chronic diseases which add fuel to the neurasthenic complaint are 
the prolonged dyspepsias which occur during the first years ; next in frequency 



368 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

are scrofula and tuberculosis, and toward puberty (in girls) chlorosis. It must 
be mentioned that the so-called anemia — the frequent accompaniment of neu- 
rasthenia — seldom depends upon a decrease of hemoglobin, but is usually due 
to an enervation of the cardiac activity and to unfavorable vasomotor stimula- 
tion of the vessels. If preparations of iron are efficacious in this condition 
their mode of action must be quite different from the ordinary. 

I shall not enter in detail into the therapy of organic affections but will 
pass on to the hygienic and dietetic treatment of neurasthenics who are not 
organically diseased, and which is also of value in hysteria. In growing chil- 
dren the nutrition must be abundant, provided there is no tendency to obesity. 
The administration of meat broths is to be limited or entirely avoided ; only in 
cases of chronic gastric dyspepsia are they indicated. Meat should be given 
but once daily, and in nervous children should be eliminated entirely in the first 
few years. One or at most two eggs are permissible, provided they are well 
borne. A vegetable diet, with a plentiful addition of milk and butter, is essen- 
tial. Instead of spices and sweets the child should be given fruit. Coffee and 
alcohol are to be forbidden. Cocoa and chocolate must be given in moderation, 
as even they may be stimulating. The meals (about five per day) are to be 
evenly distributed, and the last should not be too close to bed-time. They are 
not to be too abundant nor rich in water. 

The clothing should be simple and light, and suited to the season. Cod- 
dling is to be avoided, as well as the incomprehensible method of inurement. 
The head should be free ; the limbs, which are apt to be cool and livid, must be 
kept warm. For children who sweat readily underclothing of cotton or wool 
instead of linen is advisable. Furs and starched undergarments should be 
avoided. The neck must not be constricted nor the trousers too narrow. The 
child should have fresh, cool air even at night (60°-65° F.) and should be out 
of doors as much as possible, concern itself with play, mild sport, or light 
work, and not be permitted to become low-spirited. It is better to avoid a con- 
stant caution against taking cold, injury, and the like. Should there be slight 
accidents, as a fall, a cut, etc., not much ado should be made of it. The re- 
sistance of the skin and the power of the muscles must be strengthened. For 
poorer school-children, some auxiliary occupation in the open air is more ser- 
viceable than sitting upon the benches of charitable institutions or in their 
gloomy homes. In how far a residence at the seashore or in the mountains 
will be beneficial to the nervous but otherwise healthy child cannot always be 
determined in advance. A residence at the seacoast where there is a decided 
tide is often too exciting and gives rise to headache and restless sleep, enuresis, 
or after their return home, a relapse of bronchial asthma. Sleep should be 
abundant and should be watched on account of the possibility of onanism. 
Even older nervous children should rest for two hours after the mid-day meal. 
" Early to bed and early to rise ! " It is well known how often nervous patients 
combat this advice. 

In hydrotherapy we must individualize, as nervous persons react quite 
differently to its employment. Water improperly employed may produce a ner- 



TREATMENT OF NEURASTHENIA AND HYSTERIA 369 

vous condition; with continued and monotonous use its effect is exhausted, with 
slight periodic interruptions it invigorates and hardens. Too great cold, too 
prolonged employment of an individual method, over-strong mechanical stimu- 
lation (by the douche, by friction) must be avoided. Luke-warm half-baths, 
mild ablutions, moderate friction, brief lukewarm douches, and, with great 
unrest and insomnia, prolonged warm baths, are indicated in the individual 
case. 

An essential feature in the control of the functional neuroses which con- 
cern us here is psychic treatment. The irritable nervous weakness which we 
meet with, alone or in combination with hysteria, is usually not amenable to 
cure; it may, however, be seriously increased by unsuitable stimulation above 
the given minimum. Even immoderate bodily exertion will exhaust the nerves, 
and much more so the combination of physical and mental exertion such as is 
brought about by attending school. If at the onset a certain amount of exhaus- 
tion is present in healthy children (in addition to arrest or decrease in weight), 
in those of a nervous predisposition, as we have seen, quite a horde of neuras- 
thenic affections arises or becomes aggravated. Only the over-burdening of 
the mind by the instruction of the higher schools will be suggested here. 
Sickly children and those of feeble mentality — neurasthenics are often both — 
succumb in a marked degree to the injurious effects of school instruction. 
Here, and naturally also in private teaching, there must be an individualization 
according to the powers of tension and conception. The company of other 
children, as is brought about by attendance at school, usually serves to counter- 
act a dangerous egotism, anxious self-observation, physical and psychic effemi- 
nancy and prematurity, which might result from association with adults. In 
any event it is well to see to it that children who are mentally deficient are not 
injured by their schoolmates, and that those who are of a hysterical tempera- 
ment are not exposed to psychic contagion. 

But even prior, and in addition, to school influences other deleterious agents 
have an effect upon the nervous child. Here, since the importance of disease 
has already been emphasized, only bodily and psychic trauma will be men- 
tioned: Fright of all lands, injury, sometimes the slightest but at the same 
time unavoidable, sexual abuse, exciting experiences in the street, all give rise 
to neurasthenic or hysterical symptoms; therefore such influences should be 
avoided in so far as possible. I need only suggest the danger of children sleep- 
ing together, of intercourse with depraved playmates, visits to the circus, 
museums, theaters, the reading of newspapers, Indian stories, blood-curdling 
novels, etc. 

Most important in the treatment of infantile neurosis is the influence of the 
parents, in so far as they are an example and the companions of the child, and 
prescribe and carry out their education. If they themselves show more or less 
conspicuous nervous disturbances, corresponding conceptions are awakened 
in the child which stimulate the hysterical imagination in a definite direc- 
tion. Abnormalities in character, in the emotional temperament, in the sphere 
of the will, may produce great educational injury. In the neuropathically 
25 



370 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

predisposed child the results of parental alcoholism, poverty, or the death of 
a parent, which arise from harshness or over-indulgence, are especially early 
and severe. 

Education — in the neurosis under consideration — in hysteria and neuras- 
thenia in various strength and direction — may be preventive or may moderate 
the course and facilitate the psychic treatment of the individual symptoms. 
Aside from the training by the formation of proper conceptions and theories, 
the education should lead to a normal development of the emotions and of the 
will. Further, it should be mentioned that, as in the development of the motor 
so also in that of the psychic activity, the development of the inhibitive prop- 
erty is of importance. As the education aims in this direction in the nursling 
in the absorption of food and the discharge of the excreta, so is its tendency 
later in a more extensive degree; therefore the ingrafting of the inhibitive 
faculty is of especial value in the treatment of neurasthenia and of hysteria. 
When the physician enforces the educational requirements he must expect that 
they will develop and facilitate the normal activity of the organs by the con- 
stant alternation of exercise and rest, that they will develop the will to prompt 
and conscious action, and that the intellectual interests will expand in an altru- 
istic direction. Therefore it is necessary to combat the consideration of bodily 
conditions, in so far as this is superfluous or harmful to health, and to prevent 
a premature development of conceptions and theories which will interfere with 
the proper exercise of thoughts and actions suited to the age of the child, and 
make it precocious and inquisitive, thereby annihilating the proper educational 
influence. Simplicity, clearness, a proper sequence in the psychic development, 
self-sufficiency, and a hardening of the body should be strived for. If the more 
or less abnormal parents cannot direct the education into these channels the 
child should, if possible, be removed from its environment. Naturally, it is 
often enough difficult to find conditions which permit of a proper training. 
This is more practicable with persons of the middle class in the country or in 
small towns. 

Well-trained children, i. e., those who can be guided by proper influences, 
may occasionally suppress sensations and reflexes (cough, vomiting) due to an 
organic disease and thereby facilitate its disappearance. How much more may 
this be possible when the symptoms have their essential basis in a functional 
defect of the nervous system. If, therefore, we can successfully enlist the con- 
scious will of the patient in the treatment- of individual symptoms, this aid is 
all the more necessary, especially in hysteria, to influence in a mediate manner 
the thoughts of the patient and the actions which arise therefrom. Conceited, 
flighty, and inattentive children are exceedingly difficult to influence by any 
form of treatment. 

Indirect guidance of the will results from suggestion; it dispenses with the 
objective, true, and logical explanation and contents itself with a subjective 
proof which is evident to the patient. In rare cases only hypnosis succeeds in 
directing the unconscious thoughts into the channel intended; in most cases 
its accomplishment is possible by suggestion when the child is awake. For this 



TREATMENT OF NEURASTHENIA AND HYSTERIA ' 371 

it is necessary for the physician to have the entire confidence of the patient, 
as otherwise his statements would not be credited and would not be translated 
into instinctive conclusions; therefore the hysterical patient must not be mor- 
tified by a wrong reproach of a deliberate deception, nor must the reprimand 
be uttered by those about him. The friends and relatives had better remain 
ignorant as to the nature of the disease, as they will rarely understand the 
difference between deception and imagination, particularly when, as in hysteria, 
the one is occasionally added to the other. 

Chastisement at the proper time may occasionally, especially in young chil- 
dren, stop the tendency to vomit; retiring to bed late prevents nocturnal enu- 
resis and similar symptoms. The association of a disgreeable sensation with 
the process in question acts upon the imagination — notwithstanding the fact 
that these processes appear to be more or less remote from voluntary control of 
the will. 

As a rule, besides the actual suggestion certain logical processes of thought, 
no matter how naive, which act involuntarily, must be associated with the idea 
of repugnance: Thus drugs of a disagreeable taste, the electric current, or 
other unpleasant therapeutic agents do not act directly by the disagreeable 
sensation produced by them, but by the idea that they have a particular efficacy. 
A firm impression of this idea is usually serviceable : I take the child's head 
firmly between my hands and while he looks directly at me I utter distinctly 
the context of the conception and then have my words repeated by him. 

But the conviction of the curability, and simultaneously with this the cure, 
may be attained by other methods, for example, by gradually progressive exer- 
cises. The best exercises are those of a rhythmic nature which involve the cor- 
responding muscles upon the normal side. They ma}^ also take the form of an 
interesting amusement in which the play of the diseased and healthy muscles 
respectively is very difficult to distinguish (for example, piano playing). Or 
we may proceed by the method of irruption ("Ueberrumplung," Bruns), in 
that the patient is surprised or frightened into producing involuntary move- 
ments with the hysterically paralyzed muscles. By this means he will perceive 
the capability of movement and thus regain the power. These methods are 
various. Occasionally an energetic command is sufficient to arrest hiccough, 
crying, vomiting, and the like. However, I have more frequently seen relapses 
follow this method. It must be remarked that the unconscious processes of 
sleep (night terrors, automatic movements, somnambulistic conditions) are 
also susceptible to a certain degree to the suggestion of the wakeful period. If 
this method fails hypnotism may be tried. 

In contrast to active suggestion in neurasthenic and hysterial conditions 
is their simple neglect: The patient is treated by ignoring the symptom of 
which he complains. While he adheres to this symptom because instinctively a 
pleasant conception is associated with it (pity, admiration), by this procedure 
the patient's interest in his trouble is lessened and gradually other ideas become 
more prominent. To institute this method successfully a removal from the 
usual conditions is necessary ; therefore hospital treatment is indicated. 



372 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

If the treatment of pure hysteria has been successful it is necessary to avoid 
any future reference to the symptoms. As a matter of fact, sequels which re- 
quire further consideration are rare; for example, atrophy after prolonged 
hysterical paralysis, emaciation after tenacious vomiting. In neurasthenia the 
conditions are different! When psychic treatment has produced a cure, the 
function of the organ in question has been debilitated from the onset and re- 
mains unstable even after recovery, so that there is every reason to strengthen, 
or at least to protect, the organ from debilitating influences and to continue 
the treatment after cure. Nevertheless, in neurohysteria particularly, we must 
skillfully avoid supplying fuel to the hysterical imagination. 

I must mention a few measures which are serviceable in this sense in the 
treatment of some of the symptoms of infantile neurasthenia. A complete 
description is not my object, for they have in part merely a suggestive effect 
and therefore may be varied according to discretion ; on the other hand it is not 
necessary to detail repeatedly the necessity of a general strengthening of the 
nervous system. 

In the treatment of headache and of typical migraine mental rest and plen- 
tiful fresh air are essential. All hindrance of the circulation by clothing or by 
a sitting or stooping posture is to be prevented. Massage of the nape of the 
neck sometimes has a favorable effect, but general massage may — according to 
the vasomotor conditions present — occasionally produce the attack. Headache 
and nausea upon awakening, with pallor of the face, are ameliorated by a warm 
breakfast before rising, or by bathing with hot water, particularly of the face. 
In angiospastic headache a good symptomatic effect is produced by nitroglyc- 
erin (a one per cent, alcoholic solution in doses of one to three drops, or 1 to 
1.5 milligrams in tablet), to be taken for the attack or as a prophylactic. Ap- 
plications to the head, or binding it with a silk cloth, or the employment of the 
menthol pencil or of electricity in its various forms may be mentioned. For all 
varieties of headache doses of antipyrin, citrophen, phenacetin, etc., may be 
given according to the age, as in adults. 

The prolonged use of quinin is very serviceable for the control of headache 
and in fact all forms of nervous debility (0.03-0.1 three times daily, but not 
upon an empty stomach). Often the administration of compound tincture 
of cinchona, aromatic tincture, or the ethereal tincture of valerian (of the first, 
10 drops to a teaspoonful in sweetened water three times daily, to be taken a 
few minutes before meals; of the last two tinctures, smaller doses of 10 to 
15 drops, given in the same manner) are sufficient. In addition to these the 
cautious employment of hydrotherapy ! 

For the prevention of pseudocroup and of bronchial asthma, the therapy of 
which is not to be discussed here, acute inflammation of the respiratory pas- 
sages and especially all infectious catarrhs are to be avoided. After an infection 
has once arisen new infections readily occur, particularly in the cold months, 
and cannot positively be eluded even by a residence in a mild climate. After 
complete cure of the catarrh, never earlier, a hardening method directed against 
the changes in temperature is to be attempted. The nervous components of 



TREATMENT OF NEURASTHENIA AND HYSTERIA 373 

asthma may be decreased or even entirely overcome by a proper hydrotherapy 
of five or six weeks' duration, or by treatment with arsenic for two or three 
months. Residence at the seashore is not usually beneficial, but a high altitude 
is liable to have a favorable influence on the nervous system. 

Very frequently the enlarged pharyngeal tonsil has been removed to relieve 
the tendency to asthma, but always without the desired success. While the 
reflex irritation of the bronchial tree from the nose, without producing a par- 
ticularly frequent tendency to asthma, cannot be denied, the pharyngeal tonsil 
is included in this category only because of the clinical exaggeration which its 
enlargement at present commands. There is rather a certain relation between 
adenoid vegetations and the nervous disturbances of sleep which are produced 
by them through an obstruction of the nasal respiration, such as restlessness, 
unpleasant dreams, perhaps also night terrors and enuresis. But even if this 
is admitted, we are dealing only with an accidental cause in children who are 
already neurasthenic. Besides, if a favorable result should follow the removal 
of a tonsil in the individual case a suggestive influence of the operation must be 
considered. 

To prevent the nocturnal disturbances the following measures are of value: 
A light and not too plentiful evening meal deficient in water (therefore gruel 
or a sandwich, followed by fruit) ; retiring to bed at the earliest an hour after 
the supper. In the interval lessons, exciting games, reading and entertain- 
ment are to be denied. Before going to sleep the natural necessities are to be 
satisfied, the bedroom is to be cooled, well-ventilated and quiet, and the bed not 
too soft nor too warm. The child should fall asleep quickly — if necessary by 
the aid of command or suggestion. The hands are to be kept over the bed- 
clothes and the child is not to lie upon the abdomen. 

Whether in addition to a hindrance of nasal respiration and overloading of 
the stomach, the irritation caused by worms is capable of producing these noc- 
turnal disturbances (as is reported) is unknown to me. It is certain that any 
exciting experience during the day may influence the sleep of the nervous child 
and cause disquiet. If, after removal of the physical causes which may 
be present, the disturbance of sleep continues, suggestion may occasionally be 
employed with advantage. Among drugs, valerian (cold valerian tea given 
before bedtime) or the bromids may be considered. I shall not discuss the 
irritative conditions which arise during the night in consequence of febrile 
diseases. 

A few words must be devoted to nocturnal enuresis. Apart from the psy- 
chic treatment — punishment, the electric current and other remedies that have 
a suggestive action — repeated rousing of the patient may prevent an over-filling 
of the bladder ; or by raising the lower portion of the bed the pressure of the 
urine upon the constrictor muscle of the bladder ( ?) may be lessened. If we 
consider nocturnal enuresis in association with diurnal enuresis and with polla- 
kiuria, among the mechanical remedies the distension of the bladder by the in- 
jection of an antiseptic solution (3 per cent, boric acid) — with sufficient rins- 
ing to avoid cystitis — has often been useful. On the other hand, a suggestive 



374 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

effect is occasionally produced by the distension of the constrictor muscle by 
a large catheter. 1 

Among drugs the fluid extract of rims aromatica (10 to 15 drops three 
times daily) has shown some effect, at least so long as it is administered. The 
employment of water in the form of lukewarm Sitz baths or brief half-baths 
is useful (two to three minutes at a temperature of 30° C— 8G° F.). [Bella- 
donna in a sufficient dose at bed time will relieve the irritability of the detrusor. 
If the sphincter happens to be so weak as to allow incontinence in day time, 
strychnia with or without ergot, also the interrupted electric current, will 
strengthen it. But do not tamper with drugs; give an effective dose or leave 
them alone. — Editor.] 

Finally, a few words regarding the treatment of masturbation. The cardi- 
nal indication is to make the diagnosis. In no instance must mechanical ap- 
pliances come in contact with the genitalia ; therefore all rings, covers, and the 
like are to be rejected. Children in the first two years of life, who masturbate 
in bed, are to be lifted. According to the manner of manipulation of the hands 
the sleeves are to be crossed or fastened to the side of the bed, the lower open- 
ing in the shirt is to be sewed, or the hands are to be kept away from the sexual 
organs by a sack-like covering. If the legs are pressed together they are to be 
crossed and tied, or firm, straight sockets which are held apart by a transverse 
staff, are attached to the knees and partially envelop the upper and lower leg. 
In one case I successfully employed a board which was placed lengthwise be- 
tween the legs and passed through an opening in another board placed horizon- 
tally across the bed. Older children may wear a leather bandage during the 
night similar to swimming tights, with openings on the sides ; the front portion 
extends upward over the umbilicus; as in old armor, there is sufficient space 
in the region of the genitalia to avoid contact of the erect member with the 
bandage. Such mechanical measures are only to be introduced when close 
watching of the patient is impossible, and should be employed uninterruptedly 
for several years. 2 In cases in which onanism is practised only under certain 
circumstances the treatment is simplified. While the impulse for onanism is so 
strong in severely neuropathic children that moral instruction and logic are 
likely to be unsuccessful, in those cases which are to be regarded more as vicious 
habit education is apt to be successful. Among drugs, the occasional employ- 
ment of the salts of bromin must be considered. Too great stimulation and 
irritation by hydrotherapy should be avoided. Tiring occupation in the open 
air, as riding, bicycling, swimming, etc., divert attention from the sexual 
sphere and are therefore useful ; but it is necessary to note that these exercises 
may produce erection if there be great irritability, and they are too strenuous 
where there is great exhaustion. [Camphor and lupulin should be tried; cam- 
phor monobromate is easily taken. — Editor.] 

1 The inelastic male catheter of low number is unsuitable for catherization of boys. 

2 Special attention should be devoted to the child while on the toilet. 



ORGANIC AFFECTIONS 375 



PROGNOSIS 

In a summary of the treatment reference must be made to the prognosis. 
In hysterical as well as neurasthenic children removal from the accustomed 
environment into surroundings which are more advantageous to bodily and 
mental development is very beneficial, but usually the circumstances are such 
as to prevent a recourse to this aid. Occasionally adolescence itself brings 
about such a favorable change as to obscure the neuropathic condition for the 
time. In other cases, particularly in the hysteria of females, the disease may 
now assume a severe form. In general the symptoms of hysteria, which are 
usually monosymptomatic, and with them the symptoms of hysteria in child- 
hood, may be readily alleviated. In neurasthenia, as well as in its combina- 
tion with hysteria, a careful consideration of the individual nervous symptoms, 
particularly as they aggravate the general nervous condition, is advisable. 
Here, under some circumstances, we may interfere successfully in definite direc- 
tions. With this, in every case, the general treatment according to hygienic- 
dietetic laws must be considered, in which therapeutic measures, at first physi- 
cal, later by drugs (for example, the bromids), is to be included. Neurasthenia 
may be improved or cured the more readily if it appears somewhat acutely 
from some definite cause. The treatment is more difficult if the condition oc- 
curs in combination with organic disease (as scrofula), or with nervous affec- 
tions (as Graves' disease, epilepsy, etc.). The earlier and more severe the neu- 
ropathic hereditary degeneration is manifest the less may we count upon an 
improvement, to say nothing of a disappearance, of the nervous phenomena. 



ORGANIC AFFECTIONS 

Following neurasthenia and hysteria, and their subdivisions, a second group 
of diseases must be considered, which represents a transition from the purely 
functional to the organic affections of the nervous system : Among these are 
chorea minor (St. Vitus' dance), Graves' disease (exophthalmic goiter), and 
epilepsy. 

I need not enter into the consideration of chorea, as a special article in this 
volume is devoted to it. 1 I shall only mention that I believe its relation to 
acute rheumatic fever, in a pathogenetic respect, is very intimate and therefore 
I would include it in this group of maladies. In favor of the rheumatic nature 
of chorea is its frequency in rheumatic families — that is, in individuals rheu- 
matically predisposed — its coincidence with other rheumatic affections, its in- 
crease at particular seasons, and the like. 2 

1 B. Bendix, Chorea Minor, this volume. 

- Compare Erwin Kobrak, " Ueber rheumatische Chorea und ihre anti-rheumatische 
Therapie." Arch. f. Kinderhk., Bd. XXVI, Heft 1-2. 



376 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

Graves' Disease. — The position of Graves* disease among the neuroses is 
indefinite. Having learned to recognize the phenomena of an increase of func- 
tion of the thyroid gland through feeding it is not too much to assume that 
some of the symptoms are in relation with an enlargement of the thyroid gland. 
Upon the other hand, however, those persons are frequently attacked who are 
of a neuropathic predisposition or simultaneously present other nervous dis- 
eases which are not in causal connection with exophthalmic goiter (Basedow's 
disease). 

As the enlargement of the thyroid gland in Graves' disease, likewise as in 
simple parenchymatous goiter, is in marked dependence upon the development 
of the female sexual organs, although in what w r ay is still unknown, exophthal- 
mic goiter is rarely observed in infancy, and, similarly to hysteria, we find the 
affection distributed according to sex and age; for example, among 37 cases 
only 9 occurred in males (3 before the sixth and tenth years and 6 before the 
eleventh and fourteenth years) ; 28 among females (5 from the eighth to the 
tenth year, 24 from the eleventh to the fifteenth year). That Graves' disease 
itself, or goiter or exophthalmos, occurs in the ascendants or among brothers 
and sisters simultaneously is well known (4 times in my cases). Very severe 
types of the disease are exceptional in infancy. The individual symptoms are 
not marked — the goiter probably is most prominent — and are rarely fully de- 
veloped at the same time. Thus in the 37 cases above mentioned goiter was 
absent 6 times, exophthalmus 8 times, tacrrycardia 11 times; tremor was pres- 
ent in only 8 cases. With the exophthalmus (29 times), which was often very 
slight, a more or less distinct Graefe's sign (failure of the upper lid to follow 
the eyeball in glancing downward) was associated in 26 instances, only 7 times 
Stellwag's symptom (apparent widening of the palpebral aperture), and only 
3 times Mobius's sign (deficient convergence). In spite of common tachycar- 
dia (26 times), cardiac palpitation was rarely (12 times) complained of. 
Ascending flushes and marked sweating were rare (in 7 and 4 cases respect- 
ively). The classical triad — tachycardia, goiter, exophthalmus — was present 
only 14 times in 37 cases; 5 times the goiter w T as absent, 7 times the exophthal- 
mus, and 9 times tachycardia, the other two symptoms of the triad occur- 
ring together. In two cases there were exophthalmus and goiter; in one of 
these, however — besides Graefe's symptom — there were tremor, sweating and 
flushing; in the other case the diagnosis was rendered positive by a simul- 
taneous tremor. In contrast to the 37 positive cases of Graves' disease there 
were 12 x in wmich the combination of symptoms did not justify a positive 
diagnosis. 

Headache of varying intensity is very common in Graves' disease (22 times 
in the 37 cases). This as well as the slight irritability, may be regarded as a 
symptom of the disease, but on the other hand, as is indicated by the common 
hereditary nervous predisposition (9 in 36), may be considered a nervous dis- 

1 Oi these 12 children, 10 were females, and of these again 7 were between 11 and 
14 years of age. 



ORGANIC AFFECTIONS 377 

turbance which is commonly combined with Graves 1 disease. In these 37 cases 
the various symptoms of neurasthenia were present 13 times; once there was 
conspicuous maladie des tics, once stuttering, and 5 times hysterical phenom- 
ena. Of these 37 children 7 were of feeble mentality. 

Treatment. — The frequency with which the symptoms of irritable weak- 
ness become prominent indicates that the general measures which were ad- 
vised in the treatment of neurasthenia are to be employed here. The cautious 
use of hydrotherapy is particularly advantageous; internally arsenic — in as- 
sociation with iron, in the form of Levico water, a teaspoonful three times 
daily — given in courses of six weeks. When the symptoms are prominent 
removal from school and a residence in the country or in a moderately moun- 
tainous region are desirable. In regard to the specific treatment of exoph- 
thalmic goiter with serum, thus far nothing positive can be stated. Galva- 
nism of the cervical sympathetic may always be employed in cases of marked 
goiter and tachycardia. Cardiac palpitation may require local, cold com- 
presses. 1 

Epilepsy. — The third disease which is on the border-line between the func- 
tional disturbances of the nervous system and organic affections is epilepsy. 
Its occurrence in infancy is of great interest, if only for the reason that the 
heredity and the etiology may be discerned during this period with greater 
certainty than later. The differentiation of the epileptic attack from other 
convulsions of early childhood is naturally difficult. The separation from 
the great class of convulsions which arise from tetanoid hyperirritability has 
only lately been possible, and the differentiation from febrile convulsions and 
from that form which I designated previously as apneic arrest of breathing 
has not been made sufficiently clear. To this must be added the fact that, 
although in very rare cases, children who have first suffered from one of the 
above mentioned forms of convulsion have later developed typical epileptic 
attacks. While, under some circumstances, one variety of convulsion may 
emerge from another, in other cases, according to my positive experience, there 
is an accidental condition (for example, an infant suffering from convulsions 
due to cerebral syphilis: cured; later tetany: cured). 

Even if those not uncommon cases are left entirely out of consideration in 
which the observation of the small child yields no positive certainty regarding 
the nature of the convulsive attack, and if we adhere essentially to those cases 
which retrospectively have been rendered certain, it is shown that epilepsy 
generally begins in the first five years of life — to be exact, from the second to 
the fifth year — less commonly between the sixth and tenth years, and is some- 
what rare from then to the fourteenth year. The male sex, perhaps, is more 
greatly implicated in the first years; a preponderance in females about the 
time of sexual maturity does not occur in epilepsy, as was observed in hysteria, 
chorea, and Graves' disease. 

1 See also volume on " Diseases of the Nervous System," p. 960, et seq. 



378 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

Accurate reports are contained in the following table: 





Beginning of typical attack 


Beginning op treatment 




Males 


Females 


Total 


Males 


Females 


Total 


Under 1 year 

1 year 


4 
11 

7 
4 
3 


1 
5 
4 
5 

4 


5 
16 
11 

9 

7 


5 
5 
3 
5 


2 

2 
3 
2 


7 


2 years . . . 


7 


3 " ... 


6 


4 " 


7 






To end of 4th year 


29 


19 


48 


18 


9 


27 


5 years 


3 

1 
3 
2 
5 


2 
5 
3 
2 
6 


5 
6 
G 
4 
11 


3 
5 

2 
3 

6 


2 
2 
2 
4 

7 


5 


6 " 


7 


7 " 


4 


8 " 


7 


9 " ... 


13 






5th to 9th year 


14 


18 


32 


19 


17 


36 


10 years 


2 
3 
3 

1 


3 
2 

1 


2 
6 
5 

1 
1 


5 
4 
6 
2 


7 
5 
6 
3 
1 


12 


11 " 


9 


12 " 


12 


13 " 


5 


14 " 


1 






10th to 14th year 


9 


6 


15 


17 


22 


39 


Onset unknown 


2 


5 


7 








Total 


54 


48 


102 


54 


48 


102 



To a certain extent the reason that epilepsy occurs in early infancy is that 
at this time diseases of the brain and of its membranes, and in part also severe 
injuries to the head are most apt to occur, which later give rise to convulsions, 
especially encephalitis. But in spite of the fact that our anamnesis represents 
the greatest possible accuracy, there were among 102 cases of genuine epilepsy 
— Jacksonian epilepsy is not considered here — only 11 cases of this kind. 
An inflammation of the brain or of its membranes was noted 3 times in the 
first year, once in the fifth year, 2 times in the seventh year. An injury 
to the head which could be regarded as responsible for epilepsy, once in the 
second year, once in the fourth year, 2 times in the fifth year, once in the 
tenth year. In addition, in 9 cases organic disease existed prior to the out- 
break of the convulsions, which were perhaps in causal connection: Injury to 
the head 3 times, 6 times severe affections with prolonged unconsciousness or 
" tonic spasm " (among these once enteric fever, once scarlatina and diph- 
theria, once measles). 1 That organic changes might also be demonstrated in 
other cases, although perhaps only of a microscopic nature, can scarcely be 
doubted : This is sometimes indicated by the accompanying lack of mental 
development which naturally must not be included with weakened intelligence 

1 In these 9 cases there were only 3 of a neuropathic predisposition in so far as the 
mother was nervous or suffered from migraine. 



ORGANIC AFFECTIONS 379 

or memory, and which may appear as a consequence of the convulsive attack. 
Among 52 children 42 were of inferior mental capacity; of these 12 were 
actual imbeciles. 

While the convulsions, the origin of which may be referred to acute dis- 
eases of the brain, may appear independently of any hereditary predisposition, 
genuine epilepsy in the strict sense of the term is usually recognized as a degen- 
erative neurosis. Among nervous diseases in the ascendants, in the 91 of my 
cases which remain after deducting the 11 due to organic disease, the following 
was shown : the father or mother or both were nervous or suffered from head- 
ache or migraine in 16 cases (19 per cent.) ; once the grandmother suffered 
from head colic, once the grandfather died of a mental disease ; in the father 
or in the mother, or in their families, convulsions were noted 5 times (5 per 
cent.) ; in 3 cases the father suffered from lead intoxication, and in 8 cases he 
was addicted to alcohol (9 per cent.) ; also one case in which the mother was 
nervous. 1 Notwithstanding the fact that this small compilation gives suffi- 
cient support for the importance of a neuropathic predisposition (37 per cent.) 
too great value should not be attached to it individually. For example, the 
importance of alcoholism, although usually great stress is laid upon it, cannot 
be readily estimated, as other causal factors may be associated. 

Thus, in one of my cases the dipsomaniac father, who later developed hy- 
drocephalus, gave copious alcoholic drinks to both of his sons prior to the 
appearance of their convulsive attacks. The significance of syphilis in epilepsy 
is difficult to estimate. Even when the cases due to cerebral syphilis (with 
their usually cumulative attacks) are left out of consideration it is still con- 
ceivable that under certain circumstances the disease may be of a parasyphilitic 
nature. It is noteworthy, however, that in none of my cases of genuine epi- 
lepsy, in which, in addition to the patient the brothers and sisters were well 
known to me, could syphilis be definitely demonstrated. 

Although all forms of epilepsy are found in infancy, nevertheless their 
manner of appearance is influenced by the age and, so to speak, by the youth 
of the disease. 

Frequently epilepsy is seen in its mildest forms. In rare cases even loss 
of consciousness is absent at the onset. Thus, one of my patients who suffered 
from scarlet fever complicated by disease of the brain, at the age of 6% 
years had at first as a sequel attacks of pain and pricking in the right side of 
the head, with spasm in the forehead and right eye but without loss of con- 
sciousness, and not until the 13th year did severe typical attacks of convulsions 
develop, and, in addition, attacks of petit mal as well as psychic equivalents 
with perambulation (objectively, right-sided hemianopsia). Very frequently 
(31 times in 84 cases) epilepsy was present in the mildest form. Occasion- 
ally there was momentary unconsciousness: A transitory vertigo or loss of 
consciousness, with headache and nausea appeared, or the child had a fleeting 
rigid expression, made a grasping motion or slight contraction, or a rapid rota- 

1 In 3 cases the labor was severe (twice with forceps). 



380 FUNCTIONAL NERVOUS DISEASES OF INFANCY 

tion of the eyes. Frequently also, in these mild attacks (petit mal), there are 
convulsions of brief duration which are of a tonic nature, not at all or only 
to the slightest extent clonic and therefore are not considered as such: The 
child becomes pale, his head drops backward, or, as is more usual, he falls, 
remains prone for a few seconds or minutes with loss of consciousness, and 
the attack is over. In these milder cases sleep does not always follow, as is 
the rule in the severe forms, and an aura may precede the attack : the child is 
suddenly frightened, screams, clutches tightly (a child of one year), or runs 
around as though intoxicated, crying " I fall/' and has a simultaneous nausea 
(child aged three). Sometimes the headache, nausea, and vomiting follow 
instead of precede the attack. Among the premonitory aurae the sensation 
of pain in the abdomen must be mentioned, as well as formication. 

Occasionally these mild attacks appear at the beginning of the epileptic 
disease; but often they occur in irregular alternation with severe convulsions 
and psychic disturbances. Among 84 cases different manifestations appeared 
in the same patient in 23 instances. The great typical attacks require no 
description. Not rarely — 10 times among 84 cases — they occurred only or 
usually at night, either after falling asleep, in the course of the night, or upon 
awakening. In rare instances the attacks betrayed themselves by the invol- 
untary evacuation of urine. The initial cry and biting of the tongue are more 
rare in children than in adults, and psychic disturbances as a rule are promi- 
nent: During or after the attack the child may be silly, ill-natured, and con- 
fused. 

In rare cases the number and the severity of the attacks increase and we 
then have a status epilepticus. Here, naturally, a permanent damage occurs to 
the mental activity, whereas otherwise it is of irregular frequency and severity. 

Unfortunately it is impossible to state that the early institution of a treat- 
ment with bromids renders the prognosis of epilepsy more favorable. Al- 
though the frequency of the attacks and with this the nerve-racking effect is 
decreased, the probability of final cure does not become greater. With a diet 
in which salt is eliminated as much as possible a large dose of some bromid 
(0.5 — 2 grammes) in milk is given at night — when there are cumulative 
attacks, also in the morning — and when the convulsions have ceased a gradual 
prolongation of the interval between the doses ; for example, after a few weeks 
of this treatment the medicine is omitted one day in every six, later for two 
days, etc., until finally it is given only six days in every two weeks. 1 

Epileptic children must be under constant observation. Opportunity for 
injury during an attack must be carefully avoided ; therefore epileptics should 
not bathe in public places or be permitted to handle pointed and sharp articles 
without supervision. I discourage the sending of a child to strangers in the 

1 I have not been able to convince myself that these intermissions are advisable. 
A few days of them were sufficient to cause new attacks. That is why I warn against 
them. My night dose is equal to the sum of the two day doses. All of them are con- 
tinued through months or years. Frequent combinations are digitalis or strophanthus 
in heart affections, arsenic to protect the skin and for its general effect. — Editok. 



ORGANIC AFFECTIONS 381 

country unless there will be the same painstaking care as at home. The choice 
of an occupation presents great difficulty and usually must result in some easy 
house employment. A decision in this respect is particularly difficult, especi- 
ally if the attacks are infrequent, when there is a tendency and talent for 
some successful trade. 1 

Many paths lead from functional nervous diseases to mental affections. 
From neurasthenia the road leads over the province of psychopathic inferiority 
to degenerative psychoses ; from hysteria and from epilepsy to the mental dis- 
eases which arise from the same foundation. 

Mental disturbances are comparatively rare in infancy, and are not much 
more common after that period. There is, however, an extraordinary limi- 
tation of the psychic development which we designate, according to its degree, 
as imbecility or idiocy. Both of these conditions, as well as all other mental 
diseases of infancy, will be considered in a special volume. 

*See also volume on "Diseases of the Nervous System," p. 1012. 



CONVULSIONS IN CHILDREN 

By K. HOCHSINGER, Vienna 

Muscular spasms of clonic and tonic nature occur more commonly in 
infancy than at other periods of life. When dependent upon organic changes 
in the central nervous system they show no deviation from those of later years 
except in their greater frequency. Acute and chronic affections of the brain 
and its membranes, and the toxinfectious diseases of the central nervous sys- 
tem, for example, tetanus and hydrophobia (Lyssa), produce convulsive seiz- 
ures at any period of life. In contrast to these symptomatic convulsions 
which occur at all ages there arises in infancy — and particularly at a quite 
definite period — a second group of hyperkinesias which play a much more 
dominant role, being characterized by tonic or clonic convulsions of the vol- 
untary muscles, independent of organic disease of the central nervous system. 
The forms of spasm just mentioned are inappropriately and indiscriminately 
designated as essential or idiopathic convulsions of children and are in con- 
trast with the " symptomatic " convulsive conditions. 

If the epithet "essential " or " idiopathic " were meant to express the inde- 
pendence of the convulsions in question from other conditions its use would be 
ill-advised. 

The more we learn of the nature and causes of infantile convulsions the 
clearer does it become that even those convulsive conditions of children which 
are independent of material changes in the nervous system are no more than 
symptomatic expressions of other affections which damage the infantile organ- 
ism. Their spasmogenic action has as yet not been defined in all of its de- 
tails, but it has been determined with absolute certainty that they are able to 
generate convulsions in children without previously producing recognizable 
anatomical lesions in the central nervous system. 

To the so-called idiopathic convulsions of infancy belong eclampsia, spasm 
of the glottis, and the convulsions of tetany, since in a great majority of cases 
these are apparently substantive affections. But eclamptic attacks without 
anatomical cerebral lesions also occur in the course and as the direct conse- 
quence of other manifest infantile diseases, in which, therefore, there can be 
no question of an idiopathic character of the hyperkinesia. For example, if 
a child is attacked with convulsions during and in consequence of an eruption 
of measles they are certainly not idiopathic but are due to the action of the 
poison of morbilli upon the central nervous system. In the ordinary use of 
the term, however, they are not " symptomatic " convulsions, for, so far as is 

382 



CONVULSIONS IN CHILDREN 383 

known, they are by no means dependent upon material changes in the central 
nervous system. 

Accordingly, the division of infantile convulsions into " symptomatic " and 
" idiopathic " is neither entirely correct nor adequate. In the broadest mean- 
ing of the term all convulsions of children are symptomatic, and they must be 
either dependent upon organic lesions of the central nervous system, therefore 
" organic," or exempt from such lesions, therefore " functional." 

Nevertheless, it must be admitted that several of the functional convulsions 
of infancy naturally crystallize into other groups in their etiology and in their 
clinical picture. 

In particular there is a great group of convulsions which reveal the attrib- 
utes of a substantive disease by the typical recurrence of single attacks for a 
prolonged period and by the over-irritability of the nervous sphere during the 
interval free from attacks. These are mostly the cases which have been desig- 
nated, idiopathic eclampsia of children, but, according to the present state of 
our knowledge, will here be termed the over irritability convulsions of children. 

In a second group of convulsions the individual paroxysm has merely the 
importance of an accidental occurrence. It is an accompanying symptom of 
some clearly-defined disturbance of health, generally of an acute nature; but 
the typical repetition of the individual paroxysm, peculiar to the convulsions 
of the first group, is absent. The attack is either due to a reflex irritation of 
the spasm center (sympathetic or reflex eclampsia, Soltmann) or to some dele- 
terious agent acting upon the circulating blood or other fluids of the body 
(eclampsia haematogenes, Soltmann). The convulsions of the last named 
group occur only while the manifest disease is present. In those of hyper- 
irritability the recurrence of the same form of convulsion is the factor which 
lends to the seizures the appearance of a substantive affection, and to which 
the} r owe the designation " idiopathic." In the hematogenous and reflex 
eclampsias, however, we are concerned merely with occasional convulsive attacks 
at the onset or in the course of an acute disturbance, as at the outbreak of fever, 
after injury, from the action of some foreign body, and the like. Here belong 
also the tonic convulsions of the muscles of the extremities in very ill chil- 
dren in the first weeks of life (myotonia of the new-born), in which we are 
dealing with permanent tonic spasms, dependent for the most part, according 
to Soltmann's nomenclature, upon hematogenous causes. 

In a clinical respect an isolated position is assumed by a small group of 
infantile spasmodic conditions, namely, true tetany, in which tonic intermit- 
tent convulsions of the muscles of the extremities of quite definite form, with 
retained consciousness, are noted. Eecent authors maintain that this form 
of convulsion is dependent upon disturbances of internal secretion within the 
parathyroid glandular bodies, the so-called epithelial bodies. 

In this article we shall concern ourselves principally with functional con- 
vulsions of children, since these occupy a special position in the nosology of 
infancy, and in the main present but little resemblance to the pathology of 
later periods of life. Only in the first two years do functional convulsions 



384 CONVULSIONS IN CHILDREN 

occur with great frequency; with advancing years the tendency to spastic at- 
tacks of a functional nature constantly decreases. The convulsions due to 
organic lesions will be described in the course of this article only to such an 
extent as is necessary to comprehend the nature of convulsions of infancy. 
They will be briefly dwelt upon in the differential diagnosis. 



I. GENERAL ETIOLOGY AND PATHOGENESIS 

In any pathologic irritation which is manifested by the appearance of con- 
vulsive conditions the nerve centers may be affected as follows: 

1. Through a physiologic increase of stimulation conducted from the 
periphery to the nerve cells. 

2. Through a biologic alteration of the nerve substance, in the broadest 
sense of the term, in consequence of nutritive disturbances arising from, phys- 
ical, chemical, or toxinfectious influences. 

In an anatomical respect it must further be remembered that convulsions 
may be produced in three ways, and we must differentiate, according to the 
region from which the irritation arises : 

1. Convulsions due to direct stimulation of the buTbomedullary centers; 
2. convulsions due to direct irritation of cortical or infracortical cerebral cen- 
ters; 3. convulsions due to stimulation of sensory centripetal tracts and reflex 
stimulation of bulbomedullary or cerebral ganglion groups. 

There can be no doubt that these forms of convulsions which have been 
demonstrated experimentally and have long been recognized clinically in the 
pathology of more advanced age, also occur in childhood, for the central nerv- 
ous apparatus of children, apart from the incompleteness of the medullary 
sheaths of the conduction tracts, is organized in the same manner as the 
nervous system of advanced age. 

Starting with these premises, the question arises, how may we explain the 
occurrence of functional infantile convulsions. There can be no doubt that 
in the functional spasms of infancy only those centers and tracts can be con- 
cerned in which, under other circumstances also — i. e., experimental irritation 
or organic disease of the nervous system — the spasmodic irritation originates 
and runs its course. However, as the convulsive phenomenon in functional 
spasms does not develop from material alteration of the previously mentioned 
centers and tracts, as is the case in those due to organic lesions, and a spas- 
modic irritation is inconceivable with normal function of the parts of the 
central nervous system in question, there must be some additional factor in 
functional convulsions of infancy which is equivalent to the spasmodic irrita- 
tion of an organic lesion of the central nervous system or to one experimentally 
produced. This agent is to be found in a damage to the central nervous sys- 
tem from various external and internal influences which are conducted to the 
nervous system during the course of many infantile diseases. 

Unless we wish to enter into a discussion regarding the ultimate cause 



GENERAL ETIOLOGY AND PATHOGENESIS 385 

of infantile functional convulsions it is impossible to proceed without the intro- 
duction of an auxiliary conception. This auxiliary conception is the tend- 
ency to spasm; which cannot be sharply defined, of the first years of life, a 
"spasmophilia," by which the above-mentioned deleterious agents of internal 
and external nature produce a spastic stimulation in the nervous system in 
early childhood more readily than at later periods. It must also be added that 
during the first three years, which form the principal domain of infantile con- 
vulsions, this spasmophilia is not uniform and that some forms of convulsion 
occur only in the first months of life, while others show a preference for the 
second and third years. 

A support for the conception of infantile spasmophilia may possibly be 
found in the anatomy and physiology of the central nervous system in early 
infancy. In an anatomical respect we must remember that the central nervous 
system is not fully developed in the new-born and especially that the covering 
of the medullary sheaths of the conduction tracts and nerve fibers is still 
defective in the first months. 

In a functional respect, according to Flechsig, the new-born child, with its 
almost wholly immature cerebrum, resembles an animal with its brain removed 
in experiment. Although a great part of the functions, and in particular 
those that are necessary to life, are maintained without the cooperation of the 
cerebrum, and although, in the brainless dog, the satisfaction of the lesser 
corporeal instincts takes place without hindrance, just as in the new-born, 
nevertheless, for the performance of associated actions and movements the 
cerebrum, and particularly the cortex of the brain, is indispensable. It may be 
assumed that the nerve medulla is in intimate relation with the fullest func- 
tional activity of the nerve fibres, and that the peculiar sluggishness and help- 
lessness in the movements of the nursling are largely due to the absence of 
a covering for the medullary sheaths of the axis cylinders. The characteristic 
tendency of the new-born and of young infants to persistent tonic spasms also 
depends in great part, as will be explained later, upon the conditions which 
have already been indicated. Furthermore, we know that the cortical control 
of the motile apparatus is still incomplete in earliest infancy, and that the 
central inhibitive apparatus especially — one of the most complicated mecha- 
nisms of the nervous system — is yet quite immature. 

A third essential factor which has to do with the central nervous system 
in early childhood is the rapid growth of the brain, which in the second quarter 
of the first year progresses with particular intensity. As in all rapidly grow- 
ing tissues, a special vulnerability of the brain during this stormy period of 
development must be assumed. 

Therefore it is readily perceptible that if, during this period of rapid 
growth of the brain coincident with the psychical development, an intense 
injury of a general nature affects the entire organism of the child, the singu- 
larly sensitive nerve substance which is still undergoing development will be 
particularly implicated. 

Thus the ready excitability of the nervous sphere of the child is easily 
26 



386 CONVULSIONS IN CHILDREN 

understood. It is also self-evident that the abnormal irritability of the cere- 
brum is not so great during the first months of life as later; on the contrary, 
it only becomes obvious in the second quarter of the first year (Soltmann), 
since it goes hand in hand with the psychic development which in turn is 
intimately associated with the anatomical growth of the brain. However, as 
this psychical hyper sensitiveness, due to embryonic causes, is still unopposed 
in the later period of infancy by a strong inhibitive property of the brain, it 
is comprehensible why abnormal stimulation of the nerve centers is so fre- 
quently associated with muscular spasms, particularly in the period of life 
under consideration. 

Only by taking into account the anatomical and physiological peculiari- 
ties of the infantile central nervous system is the feeble faculty of resistance 
to external and internal influences explained, which accounts for the appear- 
ance, even upon slight stimulation and with insignificant anatomical lesions 
in the course of the central nervous apparatus, of convulsive conditions which 
would never become noticeable in older individuals under similar circum- 
stances. Reflex irritability, which also undoubtedly exists during early in- 
fancy, finds its explanation in the absence or deficient development of the 
inhibitive centers of the cerebrum, which is equivalent to an abnormally great 
vulnerability of the nervous substance. 

Nevertheless there can be scarcely a doubt that in the occurrence of infan- 
tile convulsions, in addition to other factors which will be considered in a 
special chapter of this article, individual predisposition plays an important 
role. Hereditary influences are especially noticeable. Those of long experi- 
ence and actively engaged for years in consultation and family practice cannot 
evade the fact that the children of nervous parents in particular attract atten- 
tion even in earliest life by an abnormal condition which shows itself in fre- 
quent convulsive attacks from relatively slight causes. But here other 
individual factors also come into question. It must be remembered that con- 
vulsions do not appear in all children under similar external conditions. The 
factors which give rise to convulsions do not act uniformly in all children nor 
in children of the same age. There are individuals who throughout infancy 
and until the period of pubescence are seized with convulsions from the most 
insignificant causes, for example, slight digestive disturbances, mild fever, 
or even purely psychical irritation, which have absolutely nothing in common 
with epilepsy, but it is not possible in every case to state exactly why this 
spasmophilia which is so obvious is a property peculiar only to these children. 
Although it occurs more commonly in rachitic and artificially-nourished chil- 
dren and those with a hereditary predisposition, nevertheless it may be present 
in those free of rickets, in breast-fed children, and in those without obvious 
heredity ; therefore, in the theory of infantile spasmophilia there are still many 
unsolved problems. 

In former times all functional hyperkinesias of children were declared to 
be reflex, but the more extensively the nature of infantile spasmophilia was 
studied the more obvious did it become that the old theory of reflex convulsions 



GENERAL ETIOLOGY AND PATHOGENESIS 387 

was unsatisfactory. Also external mechanical irritation involving the sen- 
sory nerves (great and sudden changes in temperature, foreign bodies, burns, 
suppuration, fissures) does not alone suffice for the production of convulsive 
attacks; on the contrary, such factors are calculated to predispose to their 
development only when a positive general spasmophilic constitution is present, 
which is indicated by an increased irritability of the central nervous system, 
and which is the actual pathologic condition of the case in question. The 
anatomical and physiological peculiarities of the central nervous system in 
first childhood may explain the tendency to convulsions, but not the " where- 
fore " of the spasm, accordingly, not the pathology of the convulsive attack, 
not the agent which in the individual case causes the transposition of the in- 
creased irritability into the convulsion. 

If the anatomical, physiological, and embryological peculiarities of the 
infantile cerebrum, in combination with definite, spasmophilic, external effects, 
were the only causes of functional infantile convulsions it would then be im- 
possible to understand why all children who are subject to the same external 
causes are not attacked by convulsions. Although this is not the case, never- 
theless, the nature of functional infantile convulsions in its final phases is 
not yet entirely clear. The conditions to some extent resemble those of 
epilepsy. In this disease also a special pathologic composition of the central 
nervous system, particularly of the cerebrum — a sort of hyperirritability of the 
latter — plays the main part, the spasmodic attacks themselves being simply 
the visible signs of the functional anomaly of the brain, the nature of which 
has not yet been explained. Experimentally in the animal it has been proven 
by Brown-Sequard, Westphal and Unverricht that certain traumatic manipu- 
lations (severing of nerves, continuous percussion upon the occipital region, 
electric stimulation of the cortex of the brain) produce a peculiar labile con- 
dition of the brain, impossible to define more accurately, which is revealed by 
frequent convulsive attacks and therefore may be regarded as a sort of arti- 
ficially-produced spasmophilia. In this respect particularly there is an analogy 
between epilepsy and the functional convulsions of children. 

What these authors have proven in their experiments upon animals is that 
the labile condition of the nervous system which tends to convulsions is natural 
in infancy, that is, there is an increased vulnerability of the nervous apparatus 
which probably in great part owes its ultimate origin to special physiological 
and anatomical relations. 

During the first two years of life this spasmophilia is especially conspicuous. 
Many authors maintain, however, that in the first weeks or months the peculiar 
tendency to convulsions does not exist. I cannot coincide with this view but 
must remark that the spasmophilia of the first weeks of life in general assumes 
a clinically different form from that of the following period. In the latter 
months of the nursing stage and during the second year of life there is a tend- 
ency to clonic and tonic convulsive conditions of intermittent character, while 
the first extrauterine period is distinguished by a tendency to permanent tonic 
convulsions. Accordingly, functional clonic convulsions of the external muscles 



388 CONVULSIONS IN CHILDREN 

and spasm of the glottis are rare occurrences in the first three months of extra- 
uterine life. With advancing age eclampsia and attacks of laryngospasm in- 
crease and in the second year of life convulsions become more common, attain- 
ing their greatest frequency at the end of the first and during the second year. 

A reason, perhaps, that eclamptic attacks and laryngospasm are rare occur- 
rences in the new-born and in very young children is the fact that the most 
important etiologic factors producing these conditions, with which we shall be- 
come familiar later, namely, respiratory noxce, in consequence of prolonged resi- 
dence in impure air, have not had an opportunity of acting upon the nervous 
system sufficiently long to produce a special hypersensitiveness of the central 
nervous apparatus. Inverseh', permanent tonic convulsions of the muscles of 
the extremities in babies, in their external representation, are by no means such 
conspicuous occurrences as are the seizures in later months, and accordingly are 
often overlooked or at least are appreciated much too little. 

With the beginning of the third year of life the tendency to spasmophilia 
decreases more and more and children who formerly were tormented by con- 
vulsions are frequently quite normal after the third year. A small number, 
however, retain a certain tendency to spasmophilia up to the age of puberty. 
These are children who, even in late childhood, are invariably seized with con- 
vulsions upon the appearance of some acute febrile disease, as a mild tonsillitis 
or a simple attack of gastric indigestion, reacting by clonic spasms and dis- 
turbance of consciousness. Such children very often remain permanently in a 
state of psychic hyperirritability, and it is an experience gained from long 
years of family practice — sit venia verbo — that the convulsive infants fre- 
quently become the nervous and hysterical children of later years. 

The predilection for the second, third, and fourth years of life of the more 
substantive functional convulsions, which according to our view depends upon 
a permanent pathological hyperirritability of the central nervous apparatus, re- 
quires a somewhat fuller discussion. 

This fact receives a satisfactory explanation if we remember that the ten- 
dency of children to convulsions depends upon an alternate relation between 
cerebral development, on the one hand, and damaging influences during this 
period, on the other. 

That the convulsive attacks due to psychical hyperirritability do not occur 
in the first weeks is readily understood, since at this period the brain does not 
exercise essential psychical function, and also because those damaging influ- 
ences which in later months give rise to eclampsia and laryngospasm have not 
had sufficient time to exert their effect. 

Between the second and fourth years the nervous system is in an unfavor- 
able constellation. The enormous psychical and cerebral development at this 
time is coincident with the appearance of one of the most widely distributed 
constitutional diseases of infancy, rachitis, to say nothing of the many influ- 
ences of infectious, alimentary, and respiratory nature which at this age have 
had a sufficient opportunity to exert their deleterious effect upon the infantile 
nervous system. 



GENERAL ETIOLOGY AND PATHOGENESIS 389 

At the end of the second year, on the one hand, the development of the 
central nervous system is more complete, and on the other, the deleterious 
factors of general nature, which have just been mentioned, become more sec- 
ondary, so that from the beginning of the third year the tendency to convul- 
sions begins to lessen. 

From our present views it is sufficiently evident that a uniform basis for 
convulsive conditions in the first }^ears of life may easily be attained if we con- 
stantly bear in mind that infantile spasmophilia depends essentially upon the 
reciprocal action of the anatomical and physiological development of the brain 
on the one side, and the influence of certain deleterious irritating factors upon 
the other. By the same line of reasoning, as we shall see later, the fact may be 
explained that every period of infancy possesses, I might say, its individual 
form of convulsion. The first two or three months are characterized by a pref- 
erence for permanent spasm of the muscles of the extremities and the absence 
of mechanical and galvanic hyperirritability of the nervous system, while the 
second half of the first year is dominated by psychical hypersensitiveness. Ac- 
cordingly, during this latter period all of those intermittent forms of convul- 
sion are to be found which are associated with clinically manifest hypersensi- 
tiveness of the nervous system. We shall not go astray if we regard hypersensi- 
tiveness of the nervous system as the basis for all of these forms, and certain 
occasional causes which cannot always be accurately defined as the causa movens 
of the isolated convulsive attack. 

In the second and third years a third, clonic and persistent, form of con- 
vulsion is added which is likewise associated with hypersensitiveness of the ner- 
vous system; the nodding spasm and spasm of the ocular muscles of children 
(so-called waddling of the head and eyes). 

Functional convulsions in children may be considered from various stand- 
points. 

First, as to the nature of the convulsions. They occur as clonic spasms or 
twitchings and as tonic spasms or contractures. 

The contractures, in turn, may be either intermittent or for a long time per- 
sistent. Accordingly we differentiate between tonic intermittent and tonic per- 
sistent or permanent spasms. Tonic and clonic convulsions are very often com- 
bined. 

Their differentiation as to localization, that is, according to the muscle 
regions affected, is very important. Convulsions of the external muscles, pre- 
dominantly clonic in character, are included under the collective term 
"eclampsia." This variety of functional spasm is in contrast with another 
form in which the muscles of respiration, therefore the internal muscles, are 
affected, the nature of the convulsion being tonic. These are the respiratory 
spasms of children, their principal representative being spasm of the glottis. 

These two varieties of convulsion, eclampsia and respiratory spasms, are 
frequently combined in an attack, so that in a clinical respect their complete 
separation is not always possible. 

Jt must be remarked that in tonic contractures of the muscles of the extrem- 



390 CONVULSIONS IN CHILDREN 

ities the intermittent forms are sometimes associated with both of the afore- 
said varieties. Only the tonic persistent convulsions of the extremities of quite 
young infants have no direct relation to the clonic convulsions of children. 

Eclamptic conditions, as we shall find later, also occur in very young in- 
fants, and it can happen that a child of this age, affected by permanent spasms, 
may be attacked by eclampsia as well. In such cases, in addition to the perma- 
nent spinal stimulation, a cortical irritative condition, either organic or tro- 
phic, has occurred, from which convulsions have arisen. 

While the respiratory spasms and the tonic intermittent contractures of the 
muscles of the extremities occupy, under all circumstances, a somewhat iso- 
lated position, and convey the impression of a substantive affection of infancy, 
the clonic convulsions of the external muscles, to which, when they occur in 
cumulative attacks, the general term " eclampsia " has been applied, are occa- 
sional accompanying phenomena of other more manifest acute or subacute dis- 
eases (eclampsia sympathica and eclampsia haemato genes of Soltmann), al- 
though in a number of cases they are of a more essential character. 

If, however, we enter into a minute investigation of the attacks of eclampsia 
in individual cases, a differentiation may perhaps be made between the forms 
of more substantive character and those which are only accompanying phe- 
nomena of some other clearly defined disease. The paroxysmal clonic convul- 
sions which occur in the course of acute diseases of infancy, and especially 
in the infections, are almost always confined to the external musculature, the 
respiratory muscles being very rarely involved. On the other hand, the eclamp- 
tic attacks which occur outside the realm of the diseases of infancy, therefore 
those of a substantive nature dependent upon general hyperirritability, are al- 
most always associated with spasm of the larynx. Accordingly, I believe that 
the external clonic muscular convulsions subordinate to other manifest 
toxinfectious diseases should be designated <e simple convulsions" and discrim- 
inated from actual " eclampsia" which is a combination of clonic external 
spasms and tonic respiratory spasms and occurs for weeks or for years in 
irregular attacks independently of other acute diseases. 

One fact must be emphasized: Children who suffer from the last-men- 
tioned form, i. e., true eclampsia, or eclampsia correctly called by that name 
may occasionally be attacked with these true eclampsias in combination with 
respiratory spasms during the course of other diseases, for it is well known 
that convulsions even of an essential nature preferably arise in infancy during 
acute intercurrent disturbances of health. It is a conspicuous fact, however, 
which in my judgment has not been sufficiently appreciated, that the convul- 
sive seizures of infancy which occur secondarily to acute disturbances of health 
rather possess the character of pure external clonic muscular contractions, 
while the clonic convulsions of more essential, substantive nature almost never 
occur without involvement of the internal muscles, especially those of respira- 
tion. 

Of great importance is the psychical state of children during the convulsive 
attacks. During the simple convulsion as well as in true eclampsia there is a 



GENERAL ETIOLOGY AND PATHOGENESIS 391 

disturbance of consciousness. Occasionally respiratory spasms, running their 
course without involvement of the external muscles, are associated with tran- 
sitory unconsciousness. It is therefore obvious that in the varieties of con- 
vulsion associated with loss of consciousness the irritant which produces the 
spasm diffusely involves the central organ of the nervous system, especially the 
cerebral cortex. Inversely, in the tonic persistent convulsions of the muscles 
of the extremities which appear in the first weeks of life loss of consciousness 
does not occur. In the tonic intermittent spasms of the muscles of the ex- 
tremities of the late nursing period there is as a rule a disturbance of con- 
sciousness. Only in the genuine carpopedal spasms of tetany * is there no 
derangement of the mental condition. 

Accordingly, we shall not go astray by regarding the convulsive eclamptic 
attacks as of cortical, and the tonic persistent convulsions of the muscles of the 
extremities and. the true tetanic spasms, respective of their sphere of irritation, 
as of subcortical or spinal origin. Perhaps even the anatomical region from 
which the spasm in functional infantile convulsions originates may be accu- 
rately determined in the individual variety of convulsions from the clinical 
picture. In true eclampsia, which is characterized by contractions in widely 
distributed muscular regions, associated with loss of consciousness, the cerebral 
cortex is positively to be regarded as that sphere from which the convulsions 
originate. Likewise, there can be no doubt that the cerebral cortex is irritated 
diffusely in all forms of convulsion in which a disturbance of consciousness 
appears. 

In the simple respiratory spasms of children a decision of the question as 
to the central point of irritation is not so easily solved. There are respiratory 
spasms of children which recur quite often with retained consciousness. To 
this category belong the milder forms of spasm of the glottis which are regu- 
larly accompanied by crowing inspiration in crying. Superficial investigation 
would seem to indicate an isolated irritation of the bulbar respiratory center, 
that is, of those ganglion groups in the bulbus which are concerned with the 
innervation of the vocal cords. 

In a large majority of the cases, however, the eclamptic attack begins with 
respiratory spasms, and a disturbance of consciousness occurs later in associa- 
tion with general convulsions. Here also the explanation might be that there 
is first a bulbar irritation of the respiratory center, the convulsions being re- 
garded as suffocative spasms which originate primarily from arrest of respira- 
tion. We should then have to consider a simultaneous irritation of Nothnagel's 
convulsive center in the medulla oblongata. 

Finally, to explain the great frequency of simple spasm of the glottis in in- 

*My view in regard to this point differs essentially from those generally held at 
present. Most authors indicate that the attacks of infantile tetany are associated 
with disturbance of consciousness because the entire subject of eclampsia and of re- 
spiratory spasms is summarized by them under the conception of " infantile tetany," 
to which I cannot agree. I regard the tetany of children as identical with tetany of 
adults, and explicit statements in this respect will appear later. 



392 CONVULSIONS IN CHILDREN 

fancy it might be assumed that, while it originates subcortically, this irritation 
arises more readily in young children because at that age inhibitions on the 
part of higher centers are slight. 

But the following exceedingly important factors are against this view, 
that the functional respiratory spasms of infancy are due to localized subcorti- 
cal irritation : 

1. Respiratory spasms of children are always associated with psychical irri- 
tation and never appear without external cause in a condition of complete men- 
tal rest. 

2. In cases associated with eclampsia and unconsciousness the latter con- 
dition occurs with such lightning-like rapidity in the initial respiratory convul- 
sion that there can be absolutely no question of its being due to an arrest of 
respiration. 

Everything indicates that the functional respiratory convulsions of chil- 
dren are also of cortical origin and that a certain psychical hyper irritability 
is the foundation of these as well as of all other forms of convulsion of later 
infancy and of early childhood, although they may be seemingly of a more 
idiopathic character. Therefore, the respiratory spasm is absent so long as an 
essential psychical activity has not yet arisen. The ultimate cause, however, is 
to be sought in a psychical hyperirritability which only becomes operative with 
the functional awakening of the brain. 

A special tendency to psychical irritability, on the one hand, and a certain 
deficiency of inhibition through higher centers, on the other, are undoubtedly 
the characteristics which are the basis of spasmophilia in early infancy. It 
must be again remarked, however, that this irritability only becomes operative 
with increasing development of the brain, therefore in the second three months 
of life. In the first two or three months all forms of convulsion are absent 
which are dependent upon psychical hyperirritability. 

In some of the peripheral nerves the degree of hypersensitiveness in certain 
forms of convulsion may be determined. Reasoning from previous explanations 
it is readily understood that a certain hyperirritability which may be demon- 
strated electrically is much more distributed in early childhood than in all 
later periods. 

While it is relatively rare in persons of advanced age and is actually pres- 
ent only in a single form of convulsion, namely, true tetany, this measurable 
hyperirritability is widely distributed in the first years of life and it is not 
rare in various forms of convulsion in children of two and three years so far 
as regards a permanent psychical hypersensitiveness. 

Following the publication in 1878 of Soltmann's experiments on young 
animals, the cause of convulsions in children was for a long time sought in the 
deficient development of the psychomotor cortical centers of the cerebrum. At 
that time this author considered that the cerebral cortex is less irritable in 
early infancy than in adults and that on account of its incomplete development 
it was not able to exert an inhibitive influence upon centers more deeply situ- 
ated. Therefore spasmodic attacks could be produced from these deeper centers, 



GENERAL ETIOLOGY AND PATHOGENESIS 393 

even with slight irritation, without receiving inhibition on the part of the cor- 
tex. According to the present status of our clinical and physiologic knowledge 
Soltmann's teaching is no longer sufficient to explain the peculiar spasmophilia 
of nurslings. 

The assumption of a lessened irritability of the cerebral cortex in general 
would presuppose that inhibitive as well as stimulative impulses arise from 
the cerebral cortex of the new-born to a much slighter extent than in later life. 

In so far as we are concerned with impulses dependent upon psychical 
influences this is correct. But it would be a mistake to conclude that the 
cerebral cortex of the new-born cannot be stimulated at all. Pathological 
anatomy teaches that new-born children with capillary hemorrhages of the 
cerebral cortex in consequence of trauma at birth are very often subject to 
tonic-clonic cortical spasms. Even unilateral traumatic and hemorrhagic 
affections of the cerebral cortex produce contralateral convulsive conditions 
which are no less severe in the first weeks of life than at any other age. From 
this it is obvious that the cerebral cortex may be directly stimulated in the 
new-born, and stimulated to the extent that irritations give rise to contra- 
lateral spasms of the extremities, notwithstanding the peculiar and even grossly 
retarded development of the central nervous system at birth. In the new-born 
child, as is well known, the white cerebral substance is quite deficient in medul- 
lary fibers. Only with the fifth extrauterine month is the medullary sheath- 
covering of the nerve fibers completed. The negative results obtained by Solt- 
mann in experiments upon new-born dogs and rabbits, in which contractions of 
the contralateral members were produced by electric stimulation of the cerebral 
cortex, discovered by Fritsch and Hitzig, appear to favor the view that the 
functions of the cortex do not take place so long as the medullary sheath-cover- 
ing of the axis cylinders is incomplete. As, however, Soltmann observed that 
this retarded condition of the cerebral cortex in new-born animals continues 
until the tenth or twelfth day of life, and from similar anatomical investiga- 
tions of the development of the medullary sheath it appeared that this imma- 
turity of the central nervous system in young animals about corresponds to the 
second or third month in the new-born child, he believed himself justified in 
assuming that in the latter, in the first two or three months of life, there were 
defects in function of the cerebral cortex similar to those in new-born animals 
in the first two weeks. 

Thus, the view that the property of conduction of the nerve fibers arises 
coincidently with medullary sheath production appeared to have much in its 
favor. Nevertheless, the experimental investigations of Paneth soon became 
known, which found that in new-born animals, notwithstanding the entire 
absence of fibers containing medullary sheaths in the motor zone, the cerebral 
cortex could be stimulated experimentally in the sense of Fritsch and Hitzig. 
Naturally this altogether coincides with the clinico-anatomical facts previously 
stated, which show that cortical diseases of the new-born may lead to convul- 
sions in the extremities of the opposite side. 

In opposition to these experimental and clinico-anatomical facts Moussous's 



394 CONVULSIONS IN CHILDREN 

explanatory attempts must appear feeble. Adhering to the insusceptibility of 
the cerebral cortex of the new-born to irritation, this author attributes a spe- 
cial significance to convulsions following traumatic obstetrical hemorrhages of 
the cerebral cortex, which would indicate that changes of this nature are always 
associated with rupture of vessels in the soft membranes of the brain, so that 
the extravasated fluid blood reaches the subarachnoid spaces and flows thither 
to the most dependent parts. In this way the extravasation comes in contact 
with the cerebral peduncles and the bulbus, from which regions spasmodic 
phenomena are said to originate by means of NothnagePs spasm center in the 
bulbus. 

To enter at this point upon a commentary of such a forced argument is 
unnecessary. The fact seated by Moussous that a great number of cortical 
affections, acquired intrauterine, run a latent course in the first weeks of life 
and do not give rise to recognizable symptoms until later is by no means op- 
posed to the possibility of a spasmodic irritability of the cerebral cortex in 
earliest childhood, as at this period of life many cases of encephalitis run their 
course with convulsive paroxysms. 

Therefore, if the view that the cerebral cortex of the new-born cannot be 
stimulated is proven to be erroneous, it is quite as positive that in early infancy 
the inhibiiive and regulating action of the cerebral cortex is incomplete. The 
peculiar conditions of the muscle tonus of new-born children, which later will 
be the subject of a comprehensive discussion, constitute the most valuable con- 
firmation of this law, which is further strengthened by the animal experiment. 

From the foregoing the very important clinical conclusion may be drawn 
that in clonic convulsions of the new-born and of young nurslings we must 
be exceedingly cautious in assuming a functional nature. In these early stages 
of life, just mentioned, shaking spasms much rather indicate an organic cere- 
bral disease than a purely functional irritation of the central nervous system. 

In regard to the reflex nervous apparatus of early childhood it may be 
stated definitely that by no means is there the degree of completeness that 
attaches to later life, and that especially the connection between the cortical 
and infracortical centers do not as yet reach that development in a functional 
respect which is present in the mature individual. Inhibition and association 
are inadequately developed in the first years of life. The confirmation of the 
reports in literature of numerous anencephalic new-born infants whose move- 
ments awaken a coordinated impression cannot alter this fact. 

In these infants there were in particular normal respiratory movements, 
and the acts of deglutition and suckling, of crying and resistance occurred 
promptly, which in any event demonstrates a certain independence of definite 
reflex acts in early infancy from cortical innervation. It is true, this merely 
proves that individual movements necessary for the daily processes are regu- 
lated without the action of higher centers, while complicated acts are coordi- 
nated, inhibited and associated only with the increasing development of the 
brain. Sufficient evidence of this is the celebrated experiment of Goltz, who 
kept a dog alive for eighteen months after the brain had been removed, and 



GENERAL ETIOLOGY AND PATHOGENESIS 395 

found that the animal could satisfy without difficulty its bodily requirements 
which were necessary for the maintenance of life. 

The nature of functional infantile convulsions cannot be understood cor- 
rectly without entering into the physiology of the muscular movements. 

We must be quite clear as to what is understood by muscular contraction 
and muscular relaxation and as to the varied muscle action in infantile con- 
vulsions, the clonic and the tonic muscular contractions, and the prolonged 
spasms. We must also be in position to decide the question : How is the action 
of stimulating and of inhibiting nerve fibers expressed upon their terminal 
organ, the musculature. 

Of great value in this explanation, which at first sight appears to be diffi- 
cult, is the theory of Kassowitz, given in the third volume of his, Biology Belat- 
ing to the Xature of Muscle Movement, which, like his entire biologic con- 
ception, is founded on the principle that all activity depends upon the forma- 
tion and destruction of the protoplasm. 

According to Kassowitz the so-called relaxation of the muscle, for which 
a more apt term would be its elongation, is just as active a process as the con- 
traction or shortening. Both of these functions depend upon the activity of 
separate nerve fibers which, in the voluntary and transversely striated muscles, 
as a rule, pass conjointly to the same nerve trunk. 

The muscle fibers, as is well known, consist of two protoplasmic substances, 
differently constructed — the actual fibrillary substance, which Kassowitz desig- 
nates myoplasma, and the surrounding intermediary substance, the so-called 
sarcoplasma. By the well-founded view of Kassowitz that each of these sub- 
stances is separately innervated, the entire problem of muscle movement and 
of inhibited movement is explained in a simple manner. With each nerve 
stimulation conducted to the fibrillary substance destruction occurs within the 
myoplasma, which must result in a shortening of the muscle in the axis of its 
fibrilli, while as much sarcoplasma is always constructed during the contraction 
as equals the amount of destroyed myoplasma. 

This causes the muscle to become thicker and shorter. 

Again, sarcoplasmic substance is destroyed by the elongating irritations of 
innervation. This causes narrowing of the muscle, and because the products of 
disintegration of the sarcoplasma serve to construct the myoplasma, the fibrilli 
gain just as much in extent in the longitudinal direction as the sarcoplasma has 
regressed in the vertical direction. 

This would explain why the volume of the contracted muscle does not be- 
come less than that of the relaxed or elongated muscle. 

Therefore, only by Kassowitz's interpretation is it obvious that, instead 
of becoming harder and firmer, the muscle is made shorter and thicker by the 
processes which take place in the fibrillary substance as the result of irritation. 
It only becomes more tense during contraction when its shortening is hindered 
by fixation of its ends, as is always the case in the uninjured living muscle. 
In the extirpated muscle the consistence in artificially produced contraction 
and elongation is always the same. 



396 CONVULSIONS IN CHILDREN 

The antagonism between destruction and construction of both of the muscle 

substances is explained by Kassowitz, in that the destroyed product of disinte- 
gration and the water of expansion are always utilized in the development of 
the other substance. Thus, the destruction of the fibrillary substance leads to 
longitudinal contraction of the muscle, but to thickening in its vertical axis. 
The reverse occurs in elongation. The change of shape in the elongating 
phase of the muscular movement depends upon the destruction of the sarco- 
plasma and upon the restoration of the fibrillary substance in the phase of 
shortening of the muscle. 

The problem of inhibition is in intimate relation to elongation of the 
m uscle. 

According to Kassowitz the inhibition of the contraction of voluntary 
muscles does not depend upon an incomprehensible destruction of the contrac- 
tion stimulation conducted to them but upon an isolated innervation of the 
sarcoplasma by which is brought about a destruction of this contractile sub- 
stance, a transposition of the liberated water of expansion to the assimilable 
products of destruction in the fibrilli, a reconstruction of the fibrillary sub- 
stance and with it an elongation of the muscle fibers. 

Charles Bell and C. Ludwig have already assumed and studied this double 
innervation of the muscular fibers and a direct action of inhibitive nerves upon 
the muscles, and have concluded that the destruction of muscular substance 
occurs through the excitomotor, the assimilation through the inhibitive nerve 
tracts. 

This conception, however, is shattered by the circumstance that the proc- 
esses of destruction and construction which lead to a change of shape of the 
muscle are referred to one and the same substance, so that the various phases of 
the muscular contraction would not be rightly interpreted. 

Only by Kassowitz's theory of the existence of separate innervation for each 
individual muscle fiber, whereby those in connection with the myoplasma pro- 
duce shortening or contraction, and those in association with the sarcoplasma 
bring about elongation or relaxation, can the effect of inhibitive fibers upon the 
muscle substance be understood. 

Accordingly, the impulse which leads to strong muscular contraction de- 
pends upon a single innervation of the fibrillary substance, and this can only 
occur through a voluntary central innervation. Every artificial stimulation of 
the muscle nerves would have to stimulate both varieties of fibers, as the irri- 
tating and inhibitive fibers proceed in the same nerve trunk. Therefore volun- 
tary muscular movement is always more intense than any artificially-produced 
contraction, because in the latter both muscle substances are brought into play 
and there is always a weakened retraction on account of the simultaneous stim- 
ulation of the elongating fibers. That muscular contraction occurs at all with 
artificial (electric) stimulation is due to the greater sensitiveness of the fibril- 
lary substance of the muscle than of the sarcoplasma. 

Therefore, stimulation, either direct or transmitted from the muscle nerve 
of both muscle substances, will cause first a reaction of the irritable myoplasma 



GENERAL ETIOLOGY AND PATHOGENESIS 397 

which will result in contraction. This muscular shortening will be relieved by 
elongation when the irritative destruction in the sarcoplasraa, which occurs 
later, has reached a sufficient degree. If, however, stimulations play upon the 
muscle in rapid sequence the latter effect alone will be observed, as the elonga- 
tion which follows the irritative destruction of the sarcoplasma always occurs 
later than the contraction due to the destruction of the fibrillary substance. 

The destruction in the sarcoplasma which succeeds the disintegration in the 
myoplasma will not be especially prominent as regards its elongating action if 
the stimulations acting upon the muscle follow one another in too rapid se- 
quence. Then the muscle-shortening effect of the permanent stimulation will 
reach its total and conceal the elongating action of the destruction of the sar- 
coplasma. 

Upon this the nature of the permanent contractions depends. But it must 
also be remarked that the degree of shortening produced by voluntary contrac- 
tion never occurs by a permanent shortening due to a direct irritation of the 
muscle or nerve, because irritation acting upon the sarcoplasma, which causes 
the muscle elongation is never entirely excluded under these circumstances 
and is to a greater or less extent opposed to the shortening effect of the destruc- 
tion of the myoplasma. 

In passing to the pathology of functional infantile convulsions much that 
was previously puzzling will be explained in the manner of appearance of these 
neuroses of infancy. 

There can be no doubt that in early infancy the influence of inhibitive 
nerve centers in the reflex movements is much less than in later life. In all 
stimulation originating from the center the irritation which leads to destruc- 
tion of the myoplasma will prevail over that which causes destruction of the 
sarcoplasma and which is associated with elongation of the muscle. If, there- 
fore, in a general irritation of the nervous system, the stimulating and inhibi- 
tive centers suffer to an equal degree, the effect of the former upon the muscu- 
lature in early childhood will always preponderate. This is the reason of the 
hardness of the muscles in convulsive attacks and the very much more promi- 
nent contractions than relaxations in infantile spasm. As, however, in a general 
stimulation of the cerebral cortex, irritations are conducted to the myoplasma 
as well as to the sarcoplasma of the muscles, as already stated, we note in all of 
those forms of convulsion' in children which are associated with disturbance 
of consciousness, therefore in which the entire cerebral cortex is stimulated, 
the occurrence of muscular spasms which are the equivalent of an alternate 
shortening and elongation in the muscular regions involved. On the other 
hand, those convulsive attacks of infancy with retained consciousness, in which 
the irritative center is subcortical or spinal, possess a predominantly tonic char- 
acter. Then we are concerned with permanent contractures because only those 
fibers are notably involved which conduct the irritative destruction to the myo- 
plasma. 

This latter condition is especially prominent in the permanent contractures 
of the extremities of the new-born. As the reflex acts of the first weeks of life 



398 CONVULSIONS IN CHILDREN 

are almost invariably of a spinal nature and the nervous inhibitive influences 
are not yet operative, we find almost exclusively, in this period, tonic spasmodic 
conditions. 

The conditions are similar in the true tetanic couvulsions of infancy, the 
origin of which must likewise be considered without an implication of the 
motor centers of the brain. 

In eclampsia, on the other hand, there is a general irritation affecting the 
cerebral cortex, as is shown by the profound disturbance in consciousness, in 
which excitomotor as well as inhibitive ganglion groups are stimulated. Here, 
accordingly, the fibrillary substance as well as the sarcoplasma are affected by 
irritative destruction and the variation in their clonic character explains the 
appearance of the convulsions. 

Of special value are the experimental findings of Soltmann in the peripheral 
nervous system of new-born animals. This author, who experimented on rab- 
bits, cats, and dogs, found that the muscle diagram of new-born animals, which 
could be obtained by electric stimulation of the nervous and muscular apparatus 
differs essentially from that of older animals. In new-born and quite young 
animals the muscle diagram showed curves of slow ascent in a slanting direc- 
tion with a right or oblique angle at the top ; the apex, therefore, was flat, and 
the descent of the curve gradual. In other words, the muscles of new-born 
animals, when under stimulation of the motor nerves, remain for a long time 
at the maximum of their contraction, and the relaxation occurs by slow degrees. 
The muscle diagram of the new-born animal is identical with that of an older 
and exhausted animal. To originate a tetanic contraction in the new-born ani- 
mal a far less frequency of stimulation is necessary than in the adult animal. 
In the latter the tetanic muscular contractions appear only after seventy inter- 
ruptions of the current per minute, while in the new-born animal they occur 
after sixteen interruptions. Soltmann quite correctly thought that he had 
found the key to these peculiar conditions of muscle irritability in the fact that 
in the first weeks of life of the child pure clonic convulsions are more rare than 
tonic spasms. 

The investigations of C. and A. Westphal have furnished valuable informa- 
tion regarding the conditions in the new-born child. Quite similarly to Flech- 
sig's reports of the central nervous organ in early infancy these investigators 
found an immature medullary development of the peripheral nerves in the 
first stage of life. In the first extrauterine weeks the peripheral nerves con- 
sist almost exclusively of nonmedullated nerve fibers ; not until the third to the 
sixth week is a marked medullary covering of the axis cylinders in evidence. 
Quite parallel to these conditions is the electric contractility. The incomplete 
structure of the nerve fibers also corresponds to a very sluggish electric irrita- 
bility which continues until about the sixth week and then gives way to normal 
values. 

The results of the investigations of Soltmann and of both Westphals closely 
coincide with Kassowitz's teachings regarding muscle movement. That the 
curve of contraction is sluggish in the new-born, that the galvanic irritability 



VARIETIES OF INFANTILE CONVULSIONS 399 

of the muscle nerves in this period of life is decreased, is unquestionably the 
consequence of a deficient development of the nerve medulla, which is to be re- 
garded as a reservoir for the metabolism of the nerves during their function. 

The exaggerated tonus of the muscles of the new-born child, which we shall 
consider in detail later, is readily explained by the slight activity of the elon- 
gating innervation in the earliest epochs of existence. 

If, as Kassowitz assumes, the elongation, i. e., the irritative destruction of 
the sarcoplasma of the muscles, depends upon the action of inhibitive fibers, it 
must be clear from previous explanations that in the new-born that condition 
of the muscle which originates from impulses of innervation conducted to the 
fibrillary substance must largely preponderate, and thus the physiologic hyper- 
tonia of the muscles of the new-born is understood. 

From these considerations the prevalence of tonic convulsions in earliest 
life also becomes comprehensible. Here the elongating innervation of the in- 
hibitive fibers, associated with the destruction of the sarcoplasma, is all the 
more secondary because normally the stimulation of the fibrillary substance, 
which produces contraction of the muscle, preponderates. 



II. VARIETIES OF INFANTILE CONVULSIONS 

Before proceeding to the clinical consideration of convulsions of infancy 
we must undertake their serviceable classification. 

It has already been remarked that the cases in which the convulsive parox- 
ysm is merely an occasional phenomenon of some sharply defined acute or sub- 
acute disturbance of health are to be differentiated from those cases in which, 
at short or long intervals for months or years, convulsions of a special kind 
recur continuously in the form of attacks, while in the interval a permanent 
hyper irritability of the central nervous system is manifest. 

As was previously stated, the first-mentioned principal group will be desig- 
nated cc occasional convulsions " of children and is to be placed in a certain 
contrast to the second group of infantile convulsions for which the serviceable 
term " liy per irritability convulsions " will be employed. 

In the occasional convulsions of children two subdivisions must be recog- 
nized : 

1. Simple convulsions or simple clonic spasms; and 2. Myotonia of the 
new-born and young infants} 

The hyper irritability convulsions include respiratory spasm and true 
eclampsia, tetany and — with some reservations — the nodding spasms of chil- 
dren. 

I. OCCASIONAL CONVULSIONS OF CHILDREN 

Those forms of convulsions may be briefly designated as occasional convul- 
sions which occur in association with acute or subacute disturbances of health 
and in which during the intervals free of attacks no symptoms of hyperirrita- 

1 See also volume on " Diseases of the Nervous System," p. 934, et seq. 



400 CONVULSIONS IN CHILDREN 

bility of the nervous system are present. The convulsive conditions with which 
we are now concerned, provided we are dealing with children beyond the first 
three months of life, are predominantly of a clonic nature, affect primarily the 
external muscles, are not associated with spasm of the glottis, and are transi- 
tory — disappearing after the acute disease has run its course. They may be 
quite properly designated as "simple clonic spasms or convulsions" and for 
the present will be considered separately. 

A. SIMPLE CLONIC SPASMS OR CONVULSIONS 

Although it has been stated that the spasmodic attacks under consideration 
are of a transitory nature and are always associated with definite and clearly 
demonstrable acute or subacute disturbances of health, it is not to be under- 
stood that these convulsions cannot recur repeatedly in the same individual. 
On the contrary, the attacks may reappear in various acute diseases affecting 
the same child, although they are then dependent upon the new affection. Ex- 
amples of these are the febrile convulsions of infancy. As is well known, there 
are children who for many years suffer from an acute spasmodic condition upon 
the occasion of an outbreak of fever. The entire realm of the so-called sympa- 
thetic or reflex eclampsias of the older authors is included here, and also Solt- 
mann's eclampsia haematogenes in so far as it pertains to the infantile convul- 
sions due to toxic causes which are soon to be considered in detail. 

The convulsive paroxysms under discussion are always associated with loss 
of consciousness but are only exceptionally introduced by prodromes. Espe- 
cially in the occasional convulsions of children of reflex origin the muscular 
contractions are very often noted immediately. The attack frequently begins 
with a lightning-like change in the color of the face and in the physiognomy. 
The child first becomes pale and wholly apathetic. This premonitory condi- 
tion lasts but a few seconds and is often accompanied by contraction of the 
muscles of expression. The actual convulsion then occurs, namely, severe spas- 
modic muscular contractions of the extremities, always associated with com- 
plete unconsciousness. 

The convulsions of the muscles of the extremities are revealed by severe 
spasmodic flexion and extension of all the limbs. The entire musculature of the 
extremities and the muscles of the abdomen and back are more rigid than nor- 
mal, and the head is usually thrown backward ; as a rule the muscles of the face 
contract spasmodically in the same tempo with the muscles of the extremities. 

The respiration is usually increased during the spasm and is sometimes 
irregular and remittent; the expiration is spasmodic. Occasionally there are 
tonic-clonic spasms of the diaphragm but never the peculiar spasms of the 
larynx characteristic of the hyperirritability convulsions which will be described 
later. Corresponding to the profound disturbance in consciousness the cuta- 
neous sensation is lost. The tongue is sometimes shoved convulsively forward 
and backward but is usually pressed against the hard palate, the mouth is closed 
spasmodically, the muscles of the jaw and of deglutition are contracted, and 
clonic convulsions of the masseters are occasionally observed. 



VARIETIES OF INFANTILE CONVULSIONS 401 

The duration of the individual attack varies from several seconds to hours. 
In prolonged spasm there is always a transitory moderation of its intensity. 

Febrile convulsions sometimes occur in a brief attack at the beginning of 
fever; occasionally they recur throughout the course of a febrile affection and 
are regenerated with each exacerbation of the fever. These initial febrile con- 
vulsions of childhood were often compared genetically with the rigors which 
characterize the onset of many febrile infectious diseases of later life. 

In some febrile infections the spasmodic attack recurs several times, but 
is always associated with a definite, sharply-limited phase of the disease. For 
example, in measles the spasmodic attacks are observed at the onset of the pro- 
dromal fever and are renewed upon the outbreak of the exanthem. Convulsions 
sometimes occur in varicella upon the appearance of the first efflorescences and 
with each further outbreak of nodules. In all septic infections of nurslings 
convulsions which attend the exacerbations of the process and are especially 
associated with pyodermia are the rule. 

With the disappearance of the spasm-producing disease the attacks which I 
have designated occasional convulsions disappear unless, prior to the disease 
which has passed, the child has suffered from spasms which belong to the realm 
of hyperirritability convulsions. With these convulsions, however, spasm of 
the larynx, as a rule, is associated — a condition which will be described later. 

However, we cannot altogether reject a certain relationship between the 
occasional convulsions of childhood and true eclampsia associated with constant 
psychic hypersensitiveness, as some of those children who have suffered from 
h^erirritability convulsions from early infancy are subject to convulsions in 
later childhood upon the most varied disturbances in health. 

The majority of the occasional convulsions of infancy depend upon the 
action of toxic products upon the central nervous system, but it must at once 
be remarked that this does not refer merely to poisons which have been intro- 
duced from without, in the restricted sense of the term, but that also an im- 
portant role must be attached to those poisons formed within the organism, in 
particular the bacterial toxins in the infectious diseases and the autointoxica- 
tion occurring in intestinal diseases of children. 

The infantile brain is much more susceptible to poisons than that of the 
adult, as may be concluded from the peculiar course of exogenous poisoning in 
infancy. Thus, intoxication with alkaloids, with carbolic acid, with iodoform, 
with potassium chlorate, etc., and especially alcoholic intoxication in early 
infancy, very frequently give rise to convulsions, while in the adult such a 
condition is altogether exceptional. Under these circumstances it cannot ap- 
pear strange that the intoxications arising within the infantile organism, par- 
ticularly those which originate from bacterial toxins and those which develop 
within the intestinal canal, give rise to quite different sjmiptoms than would 
appear in later periods of life. 

First we shall describe the occasional convulsions of childhood which occur 
in connection with accidental exogenous poisoning, since the mechanism and 
the picture of the convulsion may be regarded as representative of those intoxi- 



402 CONVULSIONS IN CHILDREN 

cations which arise in the interior of the organism from poisons due to the 
infectious diseases and from gastrointestinal autointoxication. 

Alcoholic intoxication is of special importance in children, particularly in 
nurslings, in consequence of the transmission of alcohol in the milk of the wet- 
nurse. The transmission of alcohol which had been introduced into the milk 
of the nursing woman through the mouth was demonstrated experimentally 
by Klingemann, Rosemann and Nicloux. Convulsions due to alcoholic intoxi- 
cation in nurslings following the ingestion of spirits on the part of the nursing 
woman have been repeatedly observed (Demme, Combe) ; after alcoholism in 
the wet-nurse had been discovered and corrected the symptoms of intoxication 
in the child and the convulsions always ceased. The practical employment of 
this experience would be the complete withdrawal of alcohol, even in the form 
of beer, from the diet of the nursing woman. 

In older children convulsions associated with alcoholic intoxication have 
very frequently been observed after the ingestion of spirits. In my experience 
the convulsions in acute alcoholic intoxication occur either as the precursors of 
a comatose stage or the child first falls into a deep sleep and suffers from the 
convulsive paroxysm later, during the soporose state. From my own observa- 
tion and from what I can gleam from the literature, the laryngeal muscles are 
never involved in these alcoholic convulsions of childhood. 

Practically of great importance is lead intoxication in early childhood, 
since this condition is very frequently associated with convulsions and, as a 
rule, is due to the external employment of medicaments containing lead. Espe- 
cially has intoxication associated with convulsions been noted after the employ- 
ment of Hebra's diachylon salve for extensive eczema of the face and head 
(Hahn). Putnam has shown, in a very interesting article upon lead intoxica- 
tion in infancy, that these intoxications are much more frequently associated 
with convulsions in children than in older individuals. 

Quite similar statements are true of opium poisoning in children. After 
the employment of opium in early infancy tetanoid tonic convulsions as well 
as shaking spasms have been observed. Here, as in acute alcoholic intoxica- 
tion, the convulsions may precede deep coma or occur during the soporose con- 
dition. In cases of fatal termination they may appear in a cumulative form 
prior to the terminal arrest of respiration. That even minimal doses of opium 
may be serious to infants is a well known fact, as well as the particular fre- 
quency in children of this age of an association of convulsions with opium 
poisoning. 

Noteworthy in practice are the convulsions due to santonin poisoning. The 
vermifuge loafers which are given to children and which are readily obtainable 
from the apothecary, have given rise to convulsions after the ingestion of a 
dose containing 1 decigram (1.54 grains) (Binz). In a case observed by 
Demme a dose of 1 decigram of santonin given daily for four days was suffi- 
cient to produce poisoning with severe convulsions in a child aged six years. 

These drugs do not exhaust the list of chemical agents which produce 
intoxication convulsions in children. Belladonna and mushroom poisoning 



VARIETIES OF INFANTILE CONVULSIONS 403 

may be associated with convulsions and among the drug intoxications which 
are combined with attacks of spasm must be mentioned carbolic acid and iodo- 
form poisoning in the new-born and intoxication with strychnin, bromoform, 
and male fern. 

Poisoning by antipyrin and phenacetin may produce convulsions in chil- 
dren, and especially upon the appearance of drug exanthemata. 

A case of poisoning from balsam of Peru in a child aged six years, who suc- 
cumbed to convulsions, has been reported by Lohans. The poisoning occurred 
by suckling at the nipple of the mother, which had been anointed with the 
balsam. 

We will now consider the endogenous toxic convulsions. 

As paradigmatic of this form of spasm we may consider uremic convulsions 
because they occur at all periods of life, even in earliest childhood. It is quite 
certain that some of the convulsions observed in severe intestinal affections de- 
pend upon a uremic basis, as Hohlfeld was able to demonstrate the constant 
presence of albuminuria and casts in severe gastroenteritis of infancy. Uremic 
convulsions are more common in late childhood and especially in that period 
at which scarlatina is most prevalent. 

Among the occasional spasms of endogenous toxic nature of infancy febrile 
convulsions occupy the foremost rank in frequency and importance. In the 
clinical description of simple convulsions we have already referred to their 
nature and the manner in which febrile diseases are associated with spasm. It 
need only be added that there is no febrile affection of infancy in which con- 
vulsive attacks do not occasionally occur, and that they have been observed 
throughout the entire period of childhood. 

It is true that febrile convulsions show a preference for the first three years 
of life, and the rise in temperature, therefore the hyperpyrexia, can by no 
means be regarded as the only cause of the convulsion, since the paroxysms are 
frequently seen in affections which show an elevation of temperature only 
slightly above the norm. For example, initial convulsions are frequent in mild 
attacks of influenza, especially in infancy, or in light cases of angina tonsillaris 
with but little rise of temperature. Accordingly, the convulsive irritation 
cannot be considered otherwise than due to the action of the toxic products 
produced by the infectious organisms, and here it must be remarked that the 
virus of certain affections has a special predilection for convulsions. In the 
pneumonia of children particularly, and in the acute exanthematous diseases, 
convulsions are a frequent initial symptom. 

An important role is assigned to gastrointestinal autointoxication in the 
pathogenesis of infantile convulsions. Long before the pioneer work of Bou- 
chard — " Legons sur les autointoxications dans les maladies" (1887) it was 
known that acute and chronic gastrointestinal disturbances of infancy might 
be the cause of convulsions. Indeed, in the etiology of infantile convulsions 
there is scarcely another fact so indisputable as that intestinal diseases give rise 
to spasm. In the last few years, however, we have proceeded too far, in that 
we have not been content to consider the occasional convulsions of children as 



404 CONVULSIONS IN CHILDREN 

dependent upon autointoxication, but have regarded the so-called idiopathic, 
or, as they have been termed, the hyperirritability convulsions, and the condi- 
tion of hypersensitiveness due to them, as an autotoxic sequel of gastrointesti- 
nal origin. This standpoint was especially maintained in the recent disserta- 
tion upon convulsions by D'Espine and Moussous at the French Medical Con- 
gress at Toulouse, and some modern German authorities, as Thiemich, Gregor, 
Finkelstein, Lange, Fischl, incline to the same or a very similar view. 

At another point we shall discuss the correctness of this theory. 

Gastrointestinal disturbances occasionally give rise to convulsive attacks, 
not only during infancy but also in later childhood. That children of six or 
seven years, or even beyond, may be attacked by convulsions from overloading 
of the stomach is well known to every practitioner, as well as the fact that 
constipation and the irritation of worms, especially the wandering ascarides, 
may produce the paroxysm. However, in the spasms due to the three last- 
named conditions, it is doubtful whether merely reflex processes or those of 
toxic nature are the cause of the convulsion. Of great importance and less un- 
certain in regard to their genesis are the spasms occurring in the infectious 
forms of gastroenteritis of the nursing period, immaterial whether we are deal- 
ing with endogenous or exogenous infection of the intestinal canal. In acute 
choleriform gastroenteritis convulsions occur at the onset of the disease as well 
as in the algid stage, and even in the later period of inflammatory reaction. 
Here the appearance of convulsions in various stages of the malady is depend- 
ent upon varying circumstances. In the period of acute choleriform diarrhea 
the dehydration of the tissues and especially of the nerve substance (Marshall 
Hall's hydrocephaloid) is regarded as the cause. In the later stages the general 
intoxication is made responsible for the convulsions. In fact for all forms of 
spasm occurring in the course of gastrointestinal disease in nurslings, the toxic- 
infectious factor is prominent, no matter whether it be due to the action of bac- 
terial toxins which develop during the fermentative processes in the gastroin- 
testinal canal, or whether functional changes of the liver and kidney and a dis- 
turbance of the intermediary metabolism dependent upon this are operative. 

The convulsive condition which appears in the course of gastroenteritis may 
occur in paroxysms in the abrupt form of severe shaking spasms of the muscles 
of the extremities, or a clinical picture may arise and remain for days which 
possesses a certain degree of similarity with true basilar meningitis (menin- 
gismus). It must not be overlooked that in the course of severe gastrointestinal 
disturbance organic changes may also take place in the substance of the central 
nervous system and give rise to convulsions, which must be considered in a 
differentio-diagnostic respect. The appearance of acute meningitis in conse- 
quence of gastroenteritis of nurslings, as a part phenomenon of the same gen- 
eral infection, has been demonstrated by Concetti, who, in four cases of this 
kind, found the bacterium coli in the cerebrospinal fluid. 

Clonic convulsions are more rare in the chronic digestive disturbances of 
infancy associated with atrophy than in the acute forms. Here a rigidity of 
the entire musculature of the extremities, similar to that of tetanus — the myo- 



VARIETIES OF INFANTILE CONVULSIONS 405 

tonic type, according to my nomenclature — is the more common the younger 
the child. The enterogenous athrepsia of nurslings is in many cases associated 
with the anatomical lesions of the kidney and liver, which undoubtedly causes 
a deficient function of these organs and, further, interferes with the inter- 
mediary metabolism. Occasionally, in the acute and subacute forms of gas- 
troenteritis of infancy quite similar conditions come into question. In this 
way a sort of toxemia may arise which, with an acute flooding of the organism 
with poison, causes convulsive attacks and in chronic intoxication produces a 
tetanic muscular rigidity, and also explains the characteristic coma with mus- 
cular rigidity in these nurslings in the terminal stage of the affection which 
Czerny and his pupils regard as the result of an endogenous acid intoxication. 

As to the part played by constipation in the convulsions of infancy, the im- 
portance of this pathologic condition as a causal factor has been greatly exag- 
gerated. But there is a condition due to constipation, namely, fissure of the 
rectum, in which actual convulsive attacks associated with loss of consciousness 
may occur in connection with defecation. Here the great painfulness of the 
ulceration, which is increased by straining upon the sphincter muscle during 
the act of defecation, must be regarded as the factor which gives rise to the 
convulsion. In addition we occasionally see transitory, or I might say, acute 
high-graded constipation, probably due to autointoxication, which may cause 
convulsions in older children. 

A word in regard to the relation of helminthiasis x and infantile convul- 
sions. According to Schmidt's statistics, mentioned by Moussous, relating to 
1,160 children, 56 per cent, of these children were the hosts for various forms of 
intestinal worms. 

On account of the great frequency of entozoa in the infantile intestinal 
tract, convulsions should be very much more common in children, if there were 
an intimate relation between helminthiasis and convulsions, than is actually 
the case. In my opinion a connection between helminthiasis and convulsions 
can only be maintained with certainty in regard to ascarides, the wandering of 
which into the various cavities of the body gives rise to nervous reflex spasms 
likewise as other foreign substances. I have never been convinced of the asso- 
ciation of convulsions with tape-worms, except that attacks might occur during 
the expulsion of a worm or after the administration of purgatives to expel the 
segments of the parasite. 

It must be mentioned that, the convulsions arising from intestinal worms 
have been regarded as of toxic origin, in which the poisonous products of the 
parasitic organism are ascribed a decisive role. 

We must now turn to a brief discussion of occasional convulsions of infancy 
due to reflex causes. 

There can be no doubt of the occurrence of convulsive conditions due to re- 
flex causes in infancy, and a rapid overloading of the stomach or the movement 
of intestinal parasites in the bowels may give rise to convulsions in older chil- 

1 Which is more frequent in Germany where children are often kept on coarse or 
uncooked food than with us. — Editor. 



406 CONVULSIONS IN CHILDREN 

dren, but it is necessary to enjoin caution against assigning a place to dentition 
in the etiology of infantile convulsions. Even in the works of modern authors 
we read of reflex spasms which are attributed to the rupture of a tooth. It 
cannot be emphasized too strongly that cutting of a tooth is a normal process 
of growth, that there is no sudden rupture, as occurs in perforation of an 
abscess, but that on the contrary, the gum gradually atrophies over the growing 
tooth without injury, hemorrhage or erosion. To Kassowitz 1 particularly is 
due the credit of proving the untenableness of the teaching of convulsions of 
dentition, and explaining with great enthusiasm and skill that convulsions 
which appear in children during the period of dentition are not due to teething 
but are dependent upon quite different conditions (rachitis, febrile diseases, 
and the like) which, upon minute investigation, can always be determined 
without much difficulty. 

Certain reflex accidental convulsions occur in children in connection with 
cutaneous irritation. The convulsions following burns, injuries, contusions, 
and acute inflammations of the skin belong to this category. The spasms which 
occur in severe phimosis and retention of urine, as well as in polyps and fissures 
of the rectum, and those dependent upon incarcerated testicles in the inguinal 
canal, belong to the realm of reflex accidental convulsions. That toxic influ- 
ences may also be responsible for convulsions arising in consequence of burns 
and widely distributed cutaneous inflammation requires no special remark. 

Among the physical factors which are capable of producing convulsions in 
children we must consider the effect of excessive cold or heat, although no defi- 
nite reports in regard to such an outcome are at hand. It is known, however, 
that in adults epileptiform convulsions occasionally appear after sunstroke. 

The forms of convulsions which occur in the course of pertussis and congen- 
ital disease of the heart occupy a somewhat isolated position. Here it is no 
longer possible to speak with absolute surety of functional convulsions, as 
venous stasis is always present, therefore an overfilling of the brain with 
blood, which may be a sufficient anatomical substratum for convulsions, quite 
apart from the fact that in both of these affections capillary hemorrhages into 
the substance of the brain are not uncommon. 

It is well known that very young children, especially nurslings, are not in- 
frequently attacked by convulsive spasms in the course of whooping-cough and 
that these general clonic convulsions occur in connection with the coughing 
paroxysm. They appear only in severe cases and then usually at the acme of 
the disease. If a convulsive attack once appears in the course of pertussis, in 
all probability it will not be the only paroxysm during the progress of the 
malady. In infants these attacks are of ominous import and many children 

1 Kassowitz will decline this compliment (one of many) as undeserved. Another 
Vienna author, Fleischmann, wrote on the same subject and in the same spirit 40 
years ago. He again refers to Jacobi who in 1862 published his " Dentition and Its 
Derangements," a series of lectures first published in American Medical Times. In that 
book some authors are quoted who before Kassowitz, before Fleischmann, and before 
Jacobi contradicted the popular fallacy of attributing undiagnosticated convulsions to 
dentition (or worms). — Editor. 



VARIETIES OF INFANTILE CONVULSIONS 407 

suffering from pertussis succumb when convulsions arise. Moreover it must 
be remembered that the convulsions occurring during whooping-cough are not 
merely simple functional disturbances of the central nervous system but in 
many instances are due to severe intracranial disease, especially extravasations 
of blood into the meninges and into the substance of the brain — a condition 
which is liable to occur in severe cases (See the recent comprehensive report 
of Xeurath on " Die nervosen Complicationen unci Xachkrankheiten des 
Keuchhustens." Vienna, 1904.). In older children who suffer from pertussis 
the suspicion of intracranial hemorrhage is particularly justified when they are 
attacked with convulsions and loss of consciousness. It is true that children 
who are affected by a permanent hyperirritability of the central nervous system 
are readily subject to convulsions during whooping-cough, so that the paroxysm 
of cough is merely the exciting factor of the eclamptic attack, which in children 
of this category may arise from other conditions. These attacks, however, are 
always associated with characteristic respiratory spasms. 1 They are especially 
to be feared in whooping-cough and are often the cause of sudden death. 

Quite similar convulsive paroxysms as in whooping-cough are noted not 
infrequently in infants with congenital disease of the heart and cyanosis, par- 
ticularly when they suffer from an acute affection of the respiratory passages. 

Intermittent clonic muscular spasms of the new-born require special con- 
sideration. It has been repeatedly stated that the greatest frequency of clonic 
infantile convulsions, not excluding occasional convulsions, occurs in the first 
two years of life. In the first few weeks clonic convulsions are much rarer than 
at later periods. The opinion at one time prevailed that convulsions in the 
new-born were always the result of trauma of the brain during birth, and was 
based upon Soltmann's report that simple reflex or hematogenous irritations 
were not capable of producing muscular contractions in the undeveloped cere- 
bral cortex of the new-born. Eecent observations, however, have taught that at 
this age the most varied internal and external factors may act upon the nervous 
system and produce muscular spasms. 

First, the not uncommon terminal convulsions of asphyxiated new-born in- 
fants are to be mentioned, which may depend upon venous stasis as well as ex- 
cess of carbonic acid, from which an irritation of spasmogenic ganglion groups 
arises. As a matter of fact death not infrequently occurs in the first months of 
life from convulsions in the most varied diseases. If we examine the statistics 
of convulsions collected by various authors very great contrasts will be noted 
in regard to the participation of different ages and particularly of the first 
weeks. Anyone who investigates the clinical material of hospitals for the 
manner of death of the new-born will find that convulsion is often the terminal 

1 And consequent disorders of circulation in the brain and elsewhere. Sudden death 
is not so frequent as the very many cases of paralysis, hemiplegia, epilepsy, idiocy, 
also mental backwardness attributable to whooping cough. Severe attacks should be 
stopped, by chloroform if necessary; for each may prove fatal. Such instances prove 
the criminality of the indolence of allowing whooping cough to keep on for months — 
it being " a self -limiting disease " — in place of relieving it in as many weeks. — Editor. 



408 CONVULSIONS IN CHILDREN 

act, while physicians who attend young children after the first weeks, when 
they are affected by various diseases, will state that clonic convulsions among 
these patients are not of common occurrence. All severe infections of the new- 
born, the septic diseases of the mouth, umbilicus, intestines and lungs, 
WinckePs and Buhl's diseases, and melena neonatorum, may be associated with 
convulsions. But when this age is past, when the infections and injuries con- 
nected with birth no longer come under consideration, the clonic convulsions of 
functional nature become exceedingly rare. 

To investigate the frequency of convulsions in the new-born D'Espine sent 
letters to the directors of various obstetrical clinics, who confirmed the great 
rarity of convulsions in the first days of life, but almost unanimously declared 
that clonic convulsive conditions occasionally occur versus exitum with congen- 
ital debility and in the absence of cerebral or intestinal infection. A number 
of these convulsive attacks, which are not always easy to explain, can probably 
be traced to septic infection, but another series of cases may depend upon a 
sort of autoinf ection which in some instances can be referred to a deficient func- 
tion of the parenchyma of the liver and kidneys. 

Clonic convulsive attacks with loss of consciousness also occur during the 
first weeks of life as the result of severe acute gastrointestinal diseases, in which 
there is profuse loss of fluid, causing a deficiency of water in the tissues, espe- 
cially of the brain. At this age severe inflammatory pulmonary diseases are 
not rarely associated with clonic spasmodic attacks. 

The convulsions under consideration have been designated by Thiemich 
as terminal, probably for the reason that the appearance of this condition in 
early infancy in the course of the previously-mentioned diseases is of ominous 
import and frequently introduces the agonal stage. But in spite of the con- 
vulsive attacks it is not uncommon that life is maintained in very ill infants 
provided recourse is had to an energetic introduction of water by subcutaneous 
infusion. 

The occurrence of convulsions in the new-born children of eclamptic 
mothers requires brief consideration. Without discussing the theory of eclamp- 
sia gravidarum it may be stated that, especially in the investigations of French 
authors (Moussous, Micholet, and Perret), changes in the kidneys and in the 
liver have been observed in these children quite similar to those in the eclamptic 
mother. There can be no doubt that the fetus may participate in all autointoxi- 
cations from which the mother suffers, so that an explanation of the convulsive 
phenomena in the child of an eclamptic mother cannot be very difficult, even if 
such an occurrence were common. 

Prognosis. — In regard to prognosis, the seriousness of the individual attack 
of simple convulsions is much more favorable than in true eclampsia. While 
it is no great rarity to see a child succumb to a spasm of the larynx combined 
with an eclamptic attack, simple convulsions as such, even in the severest dis- 
eases of childhood, with the exception of whooping-cough, are seldom the imme- 
diate cause of death. This does not exclude the fact that the underlying affec- 
tion which was the cause of the convulsive attack may itself bring about the 



VARIETIES OF INFANTILE CONVULSIONS 409 

fatal issue. However, experience teaches that in general the appearance of 
convulsions in the course of other affections is to be regarded as of unfavorable 
prognostic import only in infancy, and especially in the earliest period, and 
here the intestinal diseases are of more serious presage than diseases of other 
organs. 

B. MYOTONIA OF THE NEW-BORN AND YOUNG INFANTS * 

The external phenomena of the second group of occasional convulsions of 
children is to a certain extent in contrast to the class of convulsions just de- 
scribed. In the following forms of convulsions we are concerned with persist- 
ent flexor spasms of the extremities which are exclusively under the influence 
of constitutional diseases which damage the entire organism and occur only in 
eariest life. I described this peculiar spasm of the new-born and of young in- 
fants in 1900 in a special monograph on the " Myotonia of Nurslings." As 
these permanent convulsions are always dependent upon other manifest and 
easily diagnosticated affections of infancy, and, when life is retained, always 
disappear with the underlying disease, their inclusion in the group of occasional 
convulsions of children is well justified. 

We will now turn to a brief consideration of these peculiar forms of spasm 
of early childhood. 

In very sick infants, particularly those suffering, during the first weeks of 
life, from disease of the skin or of the intestines, from syphilis, or from sepsis, 
we frequently observe a peculiar change of the muscle tonus in the extremities. 
The limbs are constantly and spasmodically flexed and abducted, the hands are 
spasmodically contracted, forming a fist with included thumb or in a manner 
resembling tetany, and the toes, as a rule, are flexed spasmodically plantarward. 

Prior to my first report there were but few references in literature to the 
occurrence of such persistent convulsions of the muscles of the extremities in 
babies, and these emanated from Bednar, v. Widerhofer, Epstein, Soltmann, 
Memeyer, Henoch, Strumpell, Baginsky, Czerny and Moser, and lastly from 
Zappert. 

In the reports of some of the older authors the persistent contractures of 
the muscles of the extremities which are now under consideration have fre- 
quently been included in tetany. Such a classification was not surprising be- 
cause at that time galvanic stimulation of the muscles and nerves had not been 
practised ; otherwise the absence of electric hyperirritatbility would have indi- 
cated that these tonic convulsions of young nurslings are in no relation to 
tetany. 

Memeyer has proposed the name " arthrogryposis " for these contractures, 
and this nomenclature was in later times frequently employed for the genuine 
tetanic convulsions of infancy, although, as we shall learn later, they were al- 
together different from these permanent contractions. Henoch and Strumpell 
are opposed to the idea of a similarity of these persistent spasms or " essential 
contractures," as they designated them, to tetany. Baginsky and Escherich 

*Not to be confounded with myotonia congenita or Thomsen's disease. 



410 CONVULSIONS IN CHILDREN 

did not at first sharply differentiate these forms of spasm from tetany but have 
prohahly reached the conclusion ere now that between these permanent spasms 
of infancy and tetany there is no relationship. On the other hand, a young 
French author, Saint-Ange Eoger, has recently attempted to include the 
permanent forms of contraction of earliest life among the " formes frustes " 
of tetany, in which he holds that the absence of hyperirritability of the nervous 
system is immaterial. 

The essential criterion in the form of convulsion in question is the presence 
of symmetric, tonic flexor spasms of the extremities in children six to eight 
weeks of age, and the characteristic peculiarity that the contractures are not 
intermittent, like the genuine tetanic convulsions, but are persistent, and that 
neither galvanic nor mechanical hyperirritability of the motor nerves is present. 

In order to understand the actual condition in tonic persistent contractures 
of the extremities of early infancy it must first be pointed out that even the 
normal attitude of the new-born is characterized by a certain flexion hypertonia 
of the muscles of the extremities, which gradually disappears in later months. 
In the new-born there is a physiologic tonic flexion of the elbow- and knee- 
joints, a flexion and adduction of the hip- joint, and a slight flexure position 
of the metacarpo-phalangeal and phalangeal joints of the upper extremities 
which is not present at a later period. With this the thumb is much more 
flexed than the fingers, and occasionally somewhat included so that the last 
phalanx is hidden. The hand of the normal infant, when at rest, usually ap- 
pears as if forming a fist. This physiologic flexion of the extremities in the 
normal new-born may be readily overcome passively, but when the extremity is 
dropped it rapidly reappears. As a matter of fact, not only the flexors of the 
extremities but the entire musculature of the new-born is firmer and more rigid 
than that of older children. 

Exceptions to this are found only in myxedematous and mongoloid new- 
born and young infants in whom the physiologic hypertonus of the muscles, for 
some remarkable reason, is absent and instead, quite an opposite condition, 
namely, a peculiar flaccidity, a kind of hypotonia, is noted. In my monograph 
upon myotonia of the new-born, previously quoted, I pointed out this circum- 
stance, and particularly remarked that the position of the lower limbs, in chil- 
dren of this category, instead of being adducted and flexed at the thigh, pre- 
sent a complete abduction and outward rotation with a perfectly flaccid mus- 
culature. 

In following the process of development of a normal child it will be found 
that this flexion hypertonia does not disappear in a few days; on the con- 
trary, even under normal circumstances, this phenomenon may exist for a 
couple of months, become less marked in the third month, and disappear in the 
fourth or fifth month. 

The peculiar muscular rigidity of the new-born, as also the immoderate 
flexion hypertonia and the tendency to persistent tonic muscular convulsions, is 
very readily understood when we consider, on the one hand, the state of irrita- 
bility of the muscles and motor nerves at this age, described by Soltmann and 



VARIETIES OF INFANTILE CONVULSIONS 411 

both Westphals, and on the other, the innervation of the voluntary muscles, ex- 
plained by Kassowitz. 

In my monograph upon myotonia of the new-born an attempt was made 
to base the peculiarities of the musculature in the first weeks of life simply 
upon the results of Soltmann's experiments, from which it appeared that the 
muscles of the new-born animal, even with an exceptionally slight frequency 
of stimulation conducted to the nervous apparatus, showed tonic contraction. 
Therefore, I considered that the slight external stimulations which under 
normal circumstances are conducted to the spinal cord, that is, to the motor 
nerve roots, would act much more intensely upon the muscles of the new-born 
than upon those of older individuals. This condition would be favored by the 
absence of inhibition on the part of higher centers which exists in the earliest 
epochs of life, so that an undiminished transmission of the impulses conducted 
from without to the motor anterior roots of the spinal cord was possible. 

Nevertheless, it was incomprehensible why stimulations conducted from the 
center to the periphery gave rise exclusively to muscular contraction and never 
to elongation. In other words, the peculiar rigidity of the muscles of the new- 
born found an analogy to Soltmann's experiments in new-born animals, but its 
further nature remained altogether obscure. Only through Kassowitz's theory 
of muscular innervation, which shows that the impulses for relaxation, or elon- 
gation, of the muscles proceed in the inhibitive nerves, while those for shorten- 
ing, or contraction, of the muscle are found in the stimulating tracts, is the 
peculiarity of the musculature of the new-born explained. That this physiolo- 
gic muscle rigor is also in part associated with the incomplete development of 
the conduction tracts is obvious from the study of the muscles of premature 
infants, in whom the muscular rigidity and flexion hypertonia of the limbs are 
more distinct than in the normal child and also continue for a longer time. 

Furthermore, it is obvious that the tendency to flexion in the new-born 
must be assumed to be a continuance of the physiologic intrauterine position, 
and that in the first extra-uterine months the congenital predominance of the 
flexor muscles over the extensors which exists throughout life is exaggerated. 

From this it is easy to understand why, in severe disturbances of health 
which result in greater sensitiveness of the spinal cord and an increase of the 
stimulations which flow toward it, an exaggeration of this physiologic muscu- 
lar rigidity may extend to permanent tonic flexure convulsions. The peculiar 
myogram of the new-born, which results from electric stimulation and re- 
sembles the contraction curve of an exhausted muscle, is readily understood 
when we consider the still deficient development of the medullary sheaths in 
the conduction tracts and motor nerves in the first days or weeks of life. 

As a result of all of these circumstances the muscles of the new-born do not 
relax when numerous and intense impulses are conducted to them, therefore 
there is a condition of tonic contracture in which the flexors and adductors, 
which are already in a hypertonic condition, are principally involved. 

Under the influence of psychic irritation even in normal nurslings the 
physiologic flexion of the limbs is transitorily increased to a spasmodic flexor 



412 CONVULSIONS IN CHILDREN 

stiffening in the upper and lower extremities, whereby the hands are frequently 
doubled into a fist and the toes are flexed plantarward. But it would be incor- 
rect to regard this condition, which occurs many times daily during crying 
and screaming, as pathologic or as a transitorial stage to tetany, although in 
older children the attitudes of intermittent tetanic attacks are not dissimilar. 
This phenomenon also can be readily explained in the sense 'of Kassowitz's 
theory of muscle innervation. Muscular rigidity of young infants in conditions 
of excitement is a reflex act and occurs in the earliest age without any apparent 
cooperation of inhibitive fibers, which, as Kassowitz has explained, are exclu- 
sively associated with elongation or relaxation of the muscles. Therefore the 
muscle-shortening action of the stimulating tracts is greater during the first 
weeks of life and muscle rigidity becomes noticeable even with slight reflex 
stimulation of the motor nerves. But the spontaneous movements of a normal 
nursling, with the peculiar flexor rigidity of its extremities, result without this 
stimulation and for this reason they appear somewhat helpless and marionette- 
like. 

Between the physiologic condition of muscle tonus of the new-born, which 
finds expression in a mild flexion attitude of the extremities, and the tonic 
persistent flexor- and adduction spasms of early infancy there are numerous 
transitional stages. 

In the first six or eight weeks of life the muscle tonus is influenced in the 
sense of a hypertonia by the most varied disturbances of health, but especially 
by those of gastrointestinal nature and the prolonged inflammatory or irrita- 
tive conditions which originate from the skin. The first and most important 
evidence of a change in this respect is the appearance of the fist phenomenon, 
first described by me. If in these infants pressure is made upon the brachial 
plexus within the sulcus bicipitalis internus and the vessels are subjected to 
firm pressure by the finger upon the bones of the upper arm, or if the upper 
arm is encircled by an elastic band, a spasmodic closure of the fist is observed, 
as a rule simultaneously with the anemia of the hand from compression of the 
blood-vessels, but frequently somewhat later. The thumb is spasmodically 
flexed within the closed fingers, opposed or vertical to them; more rarely it is 
extended, completely rigid, between the first and second fingers. 

In the affected child the contracture of the fist as a rule continues some- 
what longer than the compression. Sometimes, and particularly in the milder 
cases, the fist phenomenon appears at the beginning of the compression of the 
upper arm but disappears spontaneously during the compression. 

The fist phenomenon is probably an artificial flexor contraction of the hand 
and forearm, produced reflexly, which occurs so readily during the first weeks 
of life in sick children, because the innervation of the flexors at this early age 
prevails normally to a marked degree and, as was shown by the previously men- 
tioned experiments of Soltmann, on account of the slight inhibitive action of 
higher centers, even weak stimulation at long intervals upon the motor nerves 
is sufficient to cause a tonic muscular contraction. The permanent contraction 
as such, however, is the consequence of a predominance of the innervation of 



VARIETIES OF INFANTILE CONVULSIONS 413 

the mvoplasma over that of the sarcoplasma, for in the earliest period of life 
weaker and slighter stimulations are conducted to the latter than to the fibril- 
lary substance of the muscles. 

It is of essential importance to note that the artificial development of the 
fist phenomenon disappears almost entirely after the second month of life and 
that after this epoch a tonic spasmodic phenomenon in the hand can be pro- 
duced artificially under the influence of genuine tetany, although, as we 
shall note later, spasm of the hand in genuine tetany, artificially produced, 
does not differ materially in its external aspect from the fist phenomenon just 
described. 

Trousseau's phenomenon of true tetany occurs only in older infants, and 
then notwithstanding the presence of reflex inhibitive influences from higher 
centers, because tetany is associated with decided hyperirritability of the periph- 
eral nerves by which apparently the reflex inhibitive influences of the brain 
are paralyzed. Therefore there is no contradiction in the statement that in two 
neuro-muscular disturbances of infancy, which differ essentially in their nature, 
similar symptoms may be artificially produced. 

Children in whom the fist phenomenon can be produced even in a condition 
of repose possess a more intense flexor hypertonia than is physiologic. The 
muscle substance of the flexors appears somewhat harder and the resistance to 
passive extension of the limbs is greater than under normal circumstances. 
Such children very frequently show a constant abnormal rigidity of their entire 
musculature. In more marked grades in which the tonus of the muscle is in- 
fluenced, spastic positions of the extremities are noted, presenting the type of 
conspicuous flexor contractures, which may be quite properly designated perma- 
nent spasms. In this condition the position of the hand is commonly that of 
the fist phenomenon ; more rarely it resembles the condition of tetany. In these 
persistent spasms the toes may present a claw-like plantar flexion. The flexors 
of the extremities are more prominent, rigid, and occasionally even of marble- 
like hardness. The joints are extended with difficulty, the fists can only be 
opened passively and with great exertion and are closed at once upon relaxation 
of the effort. The wrists are flexed palmarward in toto. Sometimes the entire 
hand is pronated and abducted as in tetany. Occasionally the fingers assume a 
paw-like position and the upper extremities a spastic condition which resembles 
the begging attitude of dogs. 

Nevertheless, it would be a mistake to assume that under the above circum- 
stances only the flexor muscles show a pathologic condition. Just as in the 
entire musculature of the normal new-born there is an increased tonus, so in 
these contractions there is a general pathologic rigidity, and only the functional 
preponderance of the flexors and adductors, which is normal, produces the 
flexure or adduction contraction of the limbs. 

Most intensely involved in this hypertonia are the flexor pollicis and oppo- 
nens pollicis. This is true of the physiologic as well as of the pathologic 
flexure hypertonia and also of the spontaneous permanent spasms and the fist 
phenomenon. 



414 CONVULSIONS IN CHILDREN 

The pathologic tetanoid conditions which Escherich has termed " pseudo- 
tetanus" in so far as they concern nurslings during the first weeks of life, be- 
long to the realm of myotonia. The condition is a spasmodic affection of all of 
the muscles of the body resulting from toxic influences, and therefore, in young 
infants, is only observed in severe sepsis, syphilis, or intestinal disease. On the 
other hand the pseudo-tetanic affections of Escherich which occur in later in- 
fancy belong partly to the realm of tetany and partly to genuine tetanus, and 
also to a certain extent are manifestations of hysteria. 

It must be added that in the pseudo-tetanus of infancy tonic contractures 
of the extremities occur with the arms in the position of fencing and with opis- 
thotonos and contraction of the neck, and that only one symptom which be- 
longs to true tetanus is almost invariably absent, i. e., trismus or spasm of the 
jaw. But even these varieties of spasm have been noted in high-graded pseudo- 
tetanus. 

There is no doubt in my mind that many of the cases of recovery from 
tetanus neonatorum which have been reported in literature were no more than 
severe grades of the myotonia under consideration, in which the muscles of the 
trunk were involved in addition to the muscles of the extremities. Such an 
erroneous view of pathologic conditions resembling tetanus is explained by the 
fact that severe forms of myotonia develop mainly in septic processes, and in 
particular in disease of the umbilicus, from which, as is well known, genuine 
tetanus may also originate. 

It is important to know that the spastic conditions just described have been 
more or less persistent for days or weeks, although possibly with slight remis- 
sions, that there is entire absence of pain, that these convulsions never appear 
in paroxysms as in. genuine tetany but that they develop gradually and, if the 
underlying affection has disappeared, as gradually ameliorate. 

In regard to flexion of the hand and fingers, it must be stated that even 
in persistent spasm with convulsive closure of the fist, spontaneous movements 
of the fingers, although of slight excursus, may be observed, especially when 
severe reflex irritation (prick of a pin, pinching, and the like) is applied to 
the extremities. Further, that in the pathologic myotonia of nurslings there 
is apparently a diminution of the deep reflexes which may probably be referred 
to the difficulty in movement of the rigid extremities. 

The myotonic spasms of the new-born and young infants are in no direct 
dependence upon febrile processes, although, according to the nature of the 
underlying affection, they may occur in febrile diseases. As previously men- 
tioned, diseases with high fever are occasionally associated in the earliest 
epochs of life with convulsions, and I have also observed febrile pathologic 
processes in the new-born which began with initial convulsions and later were 
followed by permanent muscular spasms of the extremities. 

Myotonia of nurslings is never a primary disease but is always dependent 
upon other disturbances of health. Very likely the muscular rigidity here 
under consideration is only the consequence of nutritive disturbance or of toxic 
influences upon the spinal cord, which manifests itself toward the periphery in 



VARIETIES OF INFANTILE CONVULSIONS 



415 



the motor end organs of the nerves of the muscles in the manner previously 
described. 

The more severe the underlying affection and the longer its duration, the 
more intense are the tonic convulsions of the extremities. Thus we find the 
most marked grades of myotonia, with a convulsive picture resembling tetanus, 
in severe and prolonged diseases associated with a toxic condition of the cen- 
tral nervous system, as in gastrointestinal autointoxication, in severe cutaneous 
inflammation, burns, and in congenital syphilis, while in slight disturbances 
of health, as a rule, only the fist phenomenon is present without persistent 
spasm. If the underlying affection is relieved the myotonic spasm dependent 





Fig. 11. — Myotonia spastica perstans 
ex enteritide chronica. atrophy. 



Fig. 12. — The same child three months 
later. Treatment in the Dresden 
Home for Infants. 



upon it also disappears. The illustrations (Figs. 11 and 12), which I owe to 
the kindness of Prof. Schlossmann of Dresden, depict the condition better than 
any description. 

Hereditary syphilis plays a great role in the etiology of myotonia neona- 
torum. According to my observations almost all children affected with florid 
congenital syphilis in the first six to eight weeks show the spasms of myotonia, 
and for the most part the spontaneous form, more rarely the artificially-pro- 
duced fist phenomenon. The dependence of the contractures upon the syphilo- 
toxic influence of the central nervous system is clearly demonstrated by the 
prompt result of treatment, as a therapy which brings about an amelioration of 
the syphilitic symptoms also gradually relieves the convulsive phenomenon. 
Myotonia of early infancy may be divided clinically into four groups : 
I. Myotonia physiologica neonatorum : Slight rigidity of the flexors of the 



416 CONVULSIONS IN CHILDREN 

extremities and a tendency to slight flexion of the fingers and toes in an other- 
wise normal child. 

II. Pathologic myotonia of the first grade: The demonstration of the fist 
phenomenon and increased general flexor hypertonia during rest. 

III. Myotonia of the second grade (myotonia spastica perstans) : Perma- 
nent tonic flexure spasms of the muscles of the extremities, particularly of the 
hands and feet (arthrogryposis, essential contracture of some authors), occur- 
ring in connection with autointoxication, severe intestinal and cutaneous dis- 
eases, hereditary syphilis, and burns. 

IV. Pseudo-tetanus : Implication of the muscles of the trunk and perhaps 
also of the face in the myotonic processes ; otherwise resembling the third group. 

In the last three groups the fist phenomenon commonly occurs within the 
first two months of life (approximately). The spontaneous persistent spasms 
of myotonia, however, occur during the entire period of infancy, although after 
the first two months they are more rare. 

The following differential factors are opposed to tetany : The contractures 
of myotonia are persistent, do not occur in paroxysms, are painless. They do 
not appear abruptly ; on the contrary, the muscular rigidity develops gradually, 
corresponding to the causal affection. There is neither mechanical nor galvanic 
hyperirritability of the nerve trunks. The facial phenomenon is never ob- 
served. Laryngospasm and eclampsia are absent. Myotonia occurs principally 
in the first weeks of life ; it is not dependent upon season, although it is more 
common in summer on account of the tendency to severe intestinal disturbance. 
There is no connection with rickets. Eelapse does not occur after the exciting 
cause is removed. Finally, treatment with phosphorus, so effectual in the 
hyperirritability spasms of the rachitic, is without influence in myotonia. 

II. HYPERIRRITABILITY CONVULSIONS OF INFANCY 

The second principal group of infantile convulsions are designated " hyper- 
irritability convulsions " because in the intervals the children in question pre- 
sent disturbances in their psychic and nerve fuctions which we have briefly ex- 
pressed by the term " hyperirritability of the nervous sphere." We must now 
explain what constitutes this hyperirritability of the nervous sphere and de- 
scribe the convulsive picture and the period free from attacks. 

The physiologic spasmophilia of early infancy, as Thiemich has quite 
properly emphasized, is not identical with the hyperirritability which is the 
basis of the variety of convulsions in question. On the contrary, we are here 
concerned with a continued pathologic condition of the central nervous appara- 
tus, particularly of the cerebral cortex, which may also be demonstrated clini- 
cally in the interval free from attacks. 

The decided tendency to convulsions which is present in the first years of 
life, even under normal circumstances, is decidedly increased under the influ- 
ence of a persistent hyperirritability of the nervous sphere, as is readily under- 
stood, so that here, inversely to the previously described occasional convulsions, 
an intense disturbance of health is not necessary for the spasmodic attacks. 



VARIETIES OF INFANTILE CONVULSIONS 417 

On the contrary, in these hypersensitive children very insignificant causes and 
even common occurrences are sufficient to produce an attack, which, in con- 
trast with the harmless occasional spasms, may be of life-threatening im- 
portance. 

Before entering into a detailed description of hyperirritability convulsions 
it must be remarked in regard to their external manifestation that a special 
form of respiratory spasm plays the most important part, whereby the clinical 
picture of this group of spasms differs from that of the occasional convulsions 
which are characterized by spastic attacks. The important form of spasm to be 
considered here is spasm of the glottis, to which, at this point, a few words must 
be devoted. In its mildest forms, as a " sighing " inspiration, or as a momen- 
tary arrest of respiration during crying, which occur daily in many children, 
it presents one of the most essential symptoms of hypersensitiveness. However, 
if the child who shows this peculiarity is closely examined it will be found that 
other symptoms denoting a hypersensitive nervous sphere are never lacking. 
Such cases are characterized throughout by an abnormal irritability of the psy- 
chic condition, by timidity, anger, often by insomnia and a special sensibility. 
Briefly, there is always a special psychic irritability which is a predominant 
characteristic. 

Many infants betray their hypersensitiveness by starting at the slightest 
noise, panting with any excitement, showing anger if their will is crossed. 
These respiratory spasms arise under quite ordinary circumstances from which 
they accidentally become excited. The attacks are often induced by anger at 
being taken from the breast before the child has finished nursing. The reason 
why these symptoms of pathologic irritability have frequently been incorrectly 
estimated is explained by the fact that in practice they are regarded as of 
secondary importance, and that gasping during crying, a daily occurrence in 
many children, has not been appreciated to a proper extent. 

These symptoms of an exaggerated irritability of the nervous sphere in in- 
fancy commonly arise between the sixth and thirtieth months, and the first 
circumstances which draw attention to the hyperirritability in question are 
the gasping of the child while crying and the crowing inspiration in psychical 
agitation. In addition to these predominant psychical phenomena very fre- 
quently there are signs of hyperirritability of the peripheral nervous system 
which are referred to mechanical and galvanic influences. Thus, in many 
children of this category ChvosteVs facial phenomenon and an increased gal- 
vanic irritability may be demonstrated which, when they occur after infancy, 
are characteristic of a quite definite functional neurosis — tetany. These cir- 
cumstances have led a number of authors to regard such convulsions of children 
as tetany. In these cases Thiemich has attached special value to the galvanic 
hyperirritability of the nerve and when increased galvanic irritability is pres- 
ent during the period free from attacks the child is declared by this author to be 
in a " tetanoid condition" Accordingly he differentiates the convulsions asso- 
ciated with galvanic hyperirritability from those in which such a condition 
cannot be demonstrated, and includes the spasmodic attacks of the first cate- 
28 



418 CONVULSIONS IN CHILDREN 

gory in the domain of tetany. For this he employed a particular factor, as we 
shall hear later, namely, the reaction to CaOC, to differentiate between the 
tetanoid and non-tetanoid convulsions of children. 

Although refraining from a discussion of these conditions until later, it 
must be remarked at this point that a positive criterion for the forms of con- 
vulsion associated with respiratory spasm and psychical hypersensitiveness is 
not to be found in the presence or absence of galvanic hyperirritability. On the 
contrary, according to my judgment, the galvanic hyperirritability of these 
children is only an accompanying phenomenon of the increased irritability of 
the entire nervous sphere which is the pathognomonic sign of the general dis- 
turbance to which these convulsive conditions are due. 

For example, we cannot admit that the spasm of the glottis has a different 
significance when the child shows a galvanic hyperirritability than if it should 
present a milder reaction, especially as definite normal values for the galvanic 
irritability in the individual months of life do not exist. Neither the clinical 
convulsive picture nor the psychic behavior of these children in the intervals 
between the attacks is changed in any manner by the presence or absence of gal- 
vanic hyperirritability. 

However, it must be stated at the outset that among the spasms of early in- 
fancy associated with general hypersensitiveness of the nervous sphere there 
is one form which coincides in all respects with the tetany of adults, so that 
we must differentiate the simple hyperirritability convulsions of children, im- 
material whether they be associated with galvanic hyperirritability, from true 
tetany in which the characteristic spontaneous or artificially-produced carpo- 
pedal contractions are present in addition to the demonstrable mechanical and 
galvanic hyperirritability. 

There could be no objection to the designation of the hyperirritability con- 
vulsions of children as " infantile tetany/'' as was done by Escherich and his 
pupil Loos, provided it were borne in mind that between the genuine tetany 
of later years and the simple hyperirritability convulsions of children there is 
a vast clinical difference. To prevent confusion it would be necessary to differ- 
entiate between " infantile tetany " and " genuine tetany of children/' I be- 
lieve it to be more serviceable to make a sharp differentiation and only to specify 
those convulsions of children as " tetany " which agree in every particular with 
the tetanic spasms of adults. Every other form of convulsion should be desig- 
nated by its clinical name such as spasm of the glottis, eclampsia, tetany, etc. 

In regard to the clinical pictures of the convulsions which here come into 
question, we must differentiate four principal forms : 

1. Respiratory spasins. 

2. Eclampsia. 

3. Genuine tetany. 

4. Nodding spasms of children. 

These are the forms of convulsion which even to-day are often designated 
idiopathic or essential convulsions of childhood because upon superficial in- 
vestigation they readily appear to be a substantive disease. We shall first 



VARIETIES OF INFANTILE CONVULSIONS 419 

describe the clinical symptoms of the individual forms of hyperirritability 
spasm and then consider the pathogenesis in general. 

A. RESPIRATORY SPASMS OP CHILDREN 

According to the phase of respiration in which the respiratory spasms occur 
it is necessary to subdivide them into two groups, the inspiratory and the ex- 
piratory forms. Until recently all respiratory convulsions of infancy were in- 
cluded under the collective term " spasm of the glottis " (laryngospasm, laryn- 
gismus stridulus). But, as Kassowitz quite correctly asserts, not all of the 
spasms of the glottis, so-called in pediatrics, are actually associated with a 
spasmodic activity of the constrictor muscles of the glottis. On the contrary, 
the respiratory convulsion very frequently manifests itself by an expiratory 
spasm, in which after a few rapid successive expirations, there is sudden com- 
plete arrest of breathing, " expiratory apnea!' 

Spasm of the glottis, in the restricted sense of the term, is a true inspira- 
tory spasm with a sudden spasmodic contraction of the glottis which may be 
recognized by a sudden crowing, gasjDing or sighing breath — the so-called 
" choking of children " — instead of the normal, quiet inspiration. Some at- 
tacks consist exclusively of these inspiratory spasms; again, there are attacks 
in which no spasmodic inspirations appear but the child ■ apparently remains 
in the expiratory stage of respiration, popularly called " arrest of breathing." 
These two forms may be combined, i. e., after an .unusually protracted, long- 
drawn-out arrest of breathing in an expiratory position no free inhalation but 
a laryngospastic, noisy inspiration results. Inversely, it may happen that an 
inspiratory spasm of the glottis introduces the attack, after which the respira- 
tion again becomes free, but subsequently, following several forcible and noisy 
inspirations there is a sudden expiratory arrest and a long time elapses before 
free inspiration again, if at all, recurs. Both forms of convulsion, provided 
they appear independently of each other, may lead to high-graded asphyxia 
and terminate fatally. Much more serious than simple inspiratory spasm of 
the glottis, as was shown by Kassowitz, are the attacks of expiratory apnea 
which are often the immediate cause of death. 

In very mild attacks, lasting but a few seconds, consciousness is not neces- 
sarily lost, but the severer attacks, particularly of expiratory apnea, begin im- 
mediately with unconsciousness. 

The more common variety of respiratory spasm is the spasm of the glottis. 
Of all the convulsions of children associated with hyperirritability this, accord- 
ing to my investigations, is the most frequent and relatively the earliest. There 
is quite a series of cases in which it has occurred substantively, i. e., without 
association with other forms of convulsion except those mild attacks of rigidity 
which occur during the course of the paroxysm and last but a few seconds. In 
many cases, however, it is an initial or partial phenomenon of a well-defined 
eclamptic attach, associated with clonic-tonic contractions of the muscles of 
the extremities and loss of consciousness. Spasm of the glottis in untreated 
cases is usually a periodically recurrent hyperkinesia which continues for sev- 



420 CONVULSIONS IN CHILDREN 

eral months and even for years. Not rarely these attacks occur daily, some- 
times repeatedly during the same day or as often as the child is subject to 
some psychical irritation. In untreated cases this condition may last from the 
sixth to the twenty-fourth month of life and even longer. 

The ordinary mild form of laryngospasm is characterized by a shrill-toned 
inspiration and a brief arrest of respiration. Naturally the sound is only the 
expression of the spasmodic adduction of the vocal cords which, upon the 
attempt to inspire air between them, results in noisy vibrations. 

The muscles herein involved are those innervated by the recurrent laryngeal 
and pneumogastric nerves, namely, the thyro-arytenoids, the crico-arytenoids, 
and the transverse arytenoids. 

In the milder cases nothing is heard but a sighing, crowing, or piping 
sound which is associated with a fruitless attempt at inspiration. Prior to 
this, for an exceedingly brief time, the child has been pale, but after the spasm 
has lasted a few seconds it will be observed that this initial pallor gives way to 
slight cyanosis. Ordinarily the extremities are extended and become somewhat 
rigid simultaneously with the crowing inspiration. 

After the inspiratory arrest has lasted a few seconds the spasm terminates 
in a deep inspiration and the attack is over. In the majority of these mild 
cases of laryngospasm the relatives of the child become accustomed to these 
paroxysms, provided only the crowing and piping sounds are heard, and attach 
no importance to them. 

In severe attacks the condition is different. Very frequently they begin 
with an expiratory arrest of breathing, quite without the crowing attempts at 
inspiration. In connection with some external irritation such as hawking, an 
examination of the larynx with a spatula, sudden chilling or pain, or some psy- 
chical irritation (crying, screaming, awakening from sleep), a quite unexpected 
and lightning-like expiratory arrest of respiration appears. The child rolls 
the eyes and presents tonic extensor spasms of the extremities, very frequently 
with tonic contractions of the hands and of the fingers. Sometimes there is 
also a simultaneous tonic contracture of the knee. The abdominal muscles 
and the diaphragm show a tonic contraction, and after this tonic spasmodic 
condition has lasted one or two minutes twitching in the extremities takes 
place. With this there is a shrill, usually crowing, sound which indicates the 
termination of the expiratory spasm and the re-entrance or, better, the spas- 
modic inhalation of air through the glottis which is but slightly opened. This 
crowing may be repeated several times at brief intervals, but finally disappears 
with the relaxation of the laryngeal muscles and a normal passage of air 
through the glottis. 

After these severe attacks the child is exhausted and often falls asleep. 
Occasionally a decided pallor of the face remains for several hours. Not al- 
ways, however, do these attacks pass off in such a harmless manner. There are 
cases in which the child suffocates in a condition of expiratory apnea. The 
crowing inspiration does not occur, as in consequence of the tonic spasm of the 
laryngeal muscles not an atom of air can pass through the glottis. This form 



VARIETIES OF INFANTILE CONVULSIONS 421 

of respiratory convulsion in particular, which hegins directly with tonic expi- 
ratory spasm, whereby the diaphragm and the muscles of respiration retain a 
spasmodic expiratory position and the muscles of the larynx are firmly con- 
tracted, is the one in which the eclamptic attacks terminate fatally and which 
Kassowitz has so classically described. 

Tracheotomy and intubation are useless in this form of expiratory apnea. 
The condition is due to a central hindrance of inspiration, to a complete fixa- 
tion of the entire respiratory musculature in the stage of expiration, which re- 
mains even when the communication of the larger respiratory passages with 
the external air becomes free. 

B. ECLAMPSIA OF CHILDHOOD 

By infantile eclampsia in its restricted sense we understand the periodic 
occurrence of tonic and clonic convulsions of the external musculature during 
the first three years of life in children who are affected by permanent hyper- 
irritability of the nervous sphere. There is no definite type of eclamptic attack. 
In their intensity and duration the convulsions are subjected to enormous 
variation. Occasionally a slight contraction of the muscles of the face, asso- 
ciated with rolling of the eyes, has the same significance symptomatically as an 
attack, lasting for hours, which begins with tonic rigidity of the extremities 
and passes into severe convulsions of the entire musculature of the body. 
Severe attacks, as a rule, present the following clinical picture: 
The scene opens almost invariably with a spasm of the larynx, mostly in- 
spiratory, but occasionally of expiratory type, combined with general muscular 
rigidity. This tonic stage with arrest of respiration seldom lasts longer than 
half a minute; the respiratory spasm then ceases and is followed by a clonic 
contraction of the muscles of the extremities of incalculable duration. Con- 
sciousness is always lost. The eyes are staring, the corneal and pupillary re- 
flexes are absent, the glance is rigid and directed into space; very frequently, 
however, the pupils are not visible, as the eyeball is rolled so far upward that 
the cornea is completely covered by the upper lid. The clonic and tonic spasms 
of the facial muscles are particularly conspicuous. Upon close investigation it 
is found that the jaws are pressed tightly together ; occasionally there is froth- 
ing at the mouth and spasmodic lateral movements of the lower jaw are exe- 
cuted with tonically contracted masseter muscles, as in genuine epileptic at- 
tacks. The respiration is labored and noisy, very often irregular ; the pulse is 
rapid and arhythmic. Frequently there is spontaneous evacuation of urine and 
feces. If the condition occurs in nurslings with an open frontal fontanelle this 
structure is found markedly protruded and tense. Severe attacks may cause 
immediate death. As a rule, however, the convulsive picture gradually resolves 
itself into an amelioration of the clonic and tonic contractions and the child 
falls into a deep sleep lasting several hours. Subsequent to the attack the 
patient is pallid and exhausted, and as a rule this lassitude continues during 
the entire succeeding day. Occasionally the post-eclamptic sleep is interrupted 
by a renewed attack. 



422 CONVULSIONS IN CHILDREN 

It is a disputed question whether or not an attack may last for hours. 
Many authors believe that the individual paroxysm is brief, not longer than a 
minute, and that prolonged attacks are merely the grouping of numerous indi- 
vidual paroxysms which pass one into another. 

The first symptom is usually a change in the facial expression. Particu- 
larly conspicuous in children, and especially in nurslings, is a wrinkling of the 
forehead, denoting a spasm of the muscles of the head and face. A fish-like 
contraction of the mouth preceding these convulsions and a change of counte- 
nance, a staring and expressionless face, indicate that very often the muscles of 
expression are involved earlier in the spasmodic condition than the muscles 
of the extremities. 

During the attack the skin is very often decidedly cyanotic, but this 
does not occur at the onset of the paroxysm; the attack is commonly intro- 
duced by marked pallor of the face, which does not give place to cyanosis until 
the appearance of respiratory spasm and arrest of expiration. The respiration 
very often does not suffer solely through spasm of the glottis and apneic attacks, 
which are only of brief duration and may recur during one and the same 
eclamptic seizure; on the contrary, difficult, stertorous respiration persists 
throughout the attack which proves that there is often tonic spasm of the en- 
tire respiratory musculature. 

In my opinion the most important criterion of genuine eclampsia is the 
presence of laryngeal spasm prior to or during the eclamptic seizures, or in the 
interval between them, immaterial whether mechanical or galvanic hyperirrita- 
bility is present in the peripheral nerves. 

A few words must be devoted to the condition of the extremities during 
the eclamptic paroxysm. 

At the onset of the attack the upper extremities are almost always in rigid 
flexion contracture. The upper arm is held tightly against the trunk, the hands 
with enclosed thumb are rounded into a fist, and also flexed. But general ex- 
tension rigidity of the large joints may also occur at the beginning of the at- 
tack, and exceptionally I have noted that the paroxysm begins with a crowing, 
laryngospastic inspiration and extensor rigidity of the limbs, with the head 
fixed posteriorly, and that flexor contracture takes the place of extensor 
rigidity only upon relaxation of the glottis. The lower extremities, apart from 
contraction, are usually in an equinus position — the toes are spasmodically 
flexed plantarward. Occasionally, quite similar to the condition in the hands, 
the halluces of the lower extremities are bent under the second and third 
toes. Very often a tonic spasm of the extremities alternates with clonic con- 
traction, which as a rule occurs rhythmically — simultaneously in the upper 
and lower limbs and in the head, I might say, in a regular tempo. Opistho- 
tonos during the entire duration of the spasm is common. When clonic con- 
tractions appear in the extremities they are usually associated with a retraction 
of the head in the same rhythm. Occasionally the contractions begin uni- 
laterally or are developed more markedly upon one side of the body than upon 
the other. 



VARIETIES OF INFANTILE CONVULSIONS 423 

C. TETANY OF CHILDREN 

There is a spasmodic clinical picture of early childhood which coincides 
in all respects with the pathologic picture of the tetany of adults : tonic, inter- 
mittent convulsions of the extremities with peculiar rigidity of the fingers and 
eventually also of the toes, retained consciousness, and increased mechanical 
and galvanic irritability of the peripheral nerves during the intervals free 
from attacks. 1 

The appearance of this disease in infancy was first reported by J. Clarke 
(1817) and Tonnele (1830). Later reports were issued by Steinheim (1830) 
and by Dance (1831). The name "tetany" was used for the first time by 
Trousseau's pupil, Corvisart, in the year 1832. It is not certain whether the 
cases which were at that time regarded as tetany of infants would be so desig- 
nated to-day. Undoubtedly some of them should be included in the group of 
simple permanent contractions and therefore cannot be included among the 
" hyperirritability convulsions." 

In infancy as well as in later life we speak of a manifest and a latent tetany. 
Regarding the conception of manifest tetany of infants there is unanimity. 
Tetany is manifest when the tonic spasms of the extremities, soon to be de- 
scribed, arise spontaneously ; tetany is to be regarded as latent if certain phe- 
nomena of an increased irritability of the nervous system are present during 
the intervals free from attack, or even with complete absence of spontaneous 
spasm of the extremities. 

The only disputed question is, which symptoms of hyperirritability exhaust 
the conception of latent tetany, that is to saj% which are sufficient for a diagno- 
sis of this condition. 

We will first relate all of the symptoms of infantile tetany which have be- 
come clinically familiar and will then discuss their value in the diagnosis of 
latent tetany. 

First in order are the spasmodic symptoms, and here we must differentiate 
between the spontaneous and artificially-produced spasms of the extremities. 
The latter, the so-called Trousseaus phenomenon, is a characteristic rigidity 
of the extremity which may be produced by constriction of the upper arm by 
means of an elastic ligature, or by pressure of the hand exerted upon the nerve 
trunks situated in the sulcus bicipitalis, for a period varying from thirty sec- 
onds to three minutes. During this artificially-produced tonic spasm the same 
condition may be recognized in the upper extremities, as is the case in the 
spontaneous spasms of tetany. The muscles of the hand and forearm are the 
most intensely affected, and particularly those supplied by the ulnar nerve. 
This causes a position of the hand which is noted in electric stimulation of the 
ulnar nerve: flexion of the fingers at the metacarpophalangeal joints, tuith 
extension of the inter phalangeal articulations and abduction of the thumb — 
the so-called " obstetric hand." This is the typical position of tetany, but in 
severe cases there may be a more marked flexion of the phalangeal joints and 
simultaneously also of the entire hand. 

1 See volume on " Diseases of the Nervous System," p. 907. 



424 CONVULSIONS IN CHILDREN 

The claw-like plantar flexion may also appear in the lower extremities in 
severe spontaneous tetany, but I have never succeeded, by constriction of the 
lower extremities, in bringing about an artificial phenomenon, in children 
affected by tetany, analogous to Trousseau's phenomenon in the upper ex- 
tremity. 

In this connection it must be stated that only the artificially-produced spas- 
modic condition of the hand with the characteristic rigidity of the fingers, 
just mentioned, in the form of the " obstetric hand " or the " writing position," 
can be regarded as Trousseaus phenomenon. A very decided resistance must 
be present when attempts are made to produce this spasm passively. A simple 
phalangeal flexion upon compression of the extremities occurs in very many 
quite normal children and is of no diagnostic importance. That the spasmodic 
closure of the fist in the employment of Trousseau's experiment during the first 
weeks of life is no proof of tetany has already been stated. 

In the cases which are characterized by spontaneous spasm Trousseau's 
phenomenon is developed readily, and especially so immediately after the ces- 
sation of a spontaneous attack. It has also been repeatedly reported to me that 
in the manifest tetany of children the production of Trousseau's sign has given 
rise to prolonged spontaneous attacks. Nor must it be overlooked that many 
hypersensitive children under the influence of Trousseau's experiment are 
seized with laryngospastic and eclamptic attacks, immaterial whether the phe- 
nomenon is actually elicited. 

Errors are very liable to arise in determining whether the flexion of the 
phalanges with included thumb, which follows constriction of the upper arm, 
is to be regarded as Trousseau's sign. In some children a kind of resistant 
movement, a flexion of the fingers, occurs which resembles this phenomenon. 
If this flexion disappears of itself in the course of a few seconds or upon pas- 
sive opening of the hand, it is not the contracture of tetany. Errors, however, 
can also occur by making too short a pressure or constriction. The affected 
hand must be completely emptied of blood and the constriction must have 
lasted at least two minutes, and only under these conditions does a negative re- 
sult indicate that Trousseau's sign cannot be elicited. 

Genuine tetanic spasms of children are associated with a definite age. They 
are rarely present before the first year of life and seldom after the close of the 
fourth. Of the external muscles only those of the extremities are involved in 
the attack. They are in toto firmer and more rigid than normal and the limbs 
are fixed in a slight flexion contracture. The muscles of the trunk remain nor- 
mal. The most important spasmodic symptom, however, is the peculiar position 
of the hand, already described. During the attack a similar rigidity may occur 
in the toes as in the fingers. 

The genuine tetanic spasms are never associated with disturbance in con- 
sciousness, except perhaps when they are introduced by a laryngospastic attack, 
which gives rise to unconsciousness but lasts only a very brief time. This con- 
dition disappears immediately upon the resumption of a normal respiratory 
condition^ The respiratory convulsions play a much more insignificant role in 



VARIETIES OF INFANTILE CONVULSIONS 425 

genuine tetany than in eclampsia and never have the threatening character of 
eclamptic conditions. There is no record of a child having succumbed to a 
tetanic contracture, and during its continuance the patient never appears to be 
an intense sufferer. In many children the contractures probably cause pain, 
as is obvious from certain resistant movements combined with crying upon 
attempts to relax the contracture passively. 

In the spontaneous attacks of tetany the causative factor cannot always be 
demonstrated definitely in the form of some psychical irritation, as is the case 
in simple hyperirritability convulsions. In many instances the spasm of the 
extremities does not occur with lightning-like suddenness as in laryngospasm 
and eclampsia. Although the first symptom of the convulsion, the phalangeal 
rigidity, appears suddenly, the stiffening of the remaining musculature is 
usually gradual, and does not involve the entire musculature of the extremities 
until later. Genuine tetany always lasts longer, rarely less than fifteen min- 
utes, and attacks continued for several hours with remissions in the intensity 
of the rigidity have frequently been reported. The spasm of genuine tetany of 
infants becomes gradually more and more intense and remains, often for hours, 
at a fixed height, and its disappearance, as a rule, is just as gradual. 

It has always been my impression that the spasm of the glottis is quite a 
secondary condition in genuine tetany, and in fact is only a proof that here 
also a general hyperirritability prevails. The tetanic spasms themselves may 
last for hours without any evidence of respiratory spasm whatsoever. Some- 
times the attack begins with laryngospasm, i. e., with a single, piping, spas- 
modic respiration, which does not usually recur during the entire duration of 
the contracture of the extremities. These genuine tetanic spasms, which must 
be differentiated from eclampsia on account of the absence of clonic muscular 
contractions, cyanosis, and unconsciousness, are relatively rare. In my expe- 
rience they only appear in a cumulative form — epidemically. Thus in Vienna 
we had an epidemic of tetany in the spring months of the years 1899 and 1900 ; 
since then the frequency of genuine tetany in our hospital has constantly de- 
creased so that in recent years I have seen scarcely more than two actual cases 
of tetany in children in any year. As a matter of fact genuine tetany is 
strictly associated with season. In Vienna it appears only in the late winter 
and in the spring months, reaching its acme in April; during the summer it 
is almost entirely absent. 

Children who suffer from spontaneous genuine tetany always present an in- 
creased mechanical and galvanic irritability of the nerves during the periods 
free from attack and constantly show Trousseaus phenomenon, as well as the 
Thiemich-Mann symptom — a specially qualified galvanic hyperirritability 
which will be considered later. 

I must caution against designating eclamptic attacks with rigidity of the 
limbs and loss of consciousness as tetany. What Elsasser has described as 
M tetanus apnoicus infantum " is not tetany but a transitory general muscular 
rigidity belonging to eclampsia which is accompanied by arrest of respiration 
and profound unconsciousness. Here quite a different spasmodic condition 



426 CONVULSIONS IN CHILDREN 

from that of tetany predominates. The muscles of the extremities are extended 
rigidly, while the hands are rounded into a fist which cannot be opened; in ad- 
dition the head is spasmodically fixed posteriorly, the face is blue, there is 
frothing at the mouth, and the muscles of the trunk are in a state of tonic 
spasm. As a rule this tonic stage is succeeded by a clonic contraction of the 
muscles of the face and trunk, which is a symptom foreign to tetany. The con- 
dition is due to a cortical irritation, while the irritative sphere in genuine 
tetany is predominantly infracortical, that is, of spinal origin. 

A symptom that is never absent in the genuine tetany of infancy is the 
mechanical liyperirritability of the motor nerves. In all children who are 
subject to tetany this liyperirritability can be demonstrated in the facial nerve. 
To produce this facial phenomenon, which was discovered by Chvostek in 
1876, and named for him, palpation of the pre-auricular portion of the cheek 
is necessary. When the liyperirritability is decided, a simple stroking of the 
cheek with the finger or with the shaft of a percussion hammer produces a 
lightning-like contraction in this muscular region of the face. 

The facial phenomenon of tetany is in general more markedly developed 
in infancy than in later life. Neither in manifest nor in latent tetany is it 
absent. It is very frequently observed in children who are free from tetany 
and is especially common in those who suffer from a general hypersensitiveness 
of the nervous sphere. Accordingly, it is a common symptom in rachitic chil- 
dren who are subject to respiratory spasm. 

The facial phenomenon is the expression of an increased irritability of the 
nerves of the face. There are hypersensitive children in whom a slight touch 
of the cheek with the finger is sufficient to produce an intense lightning-like 
contraction of all of the facial muscles upon the side in question. This con- 
dition can no longer be recognized as a symptom of tetany exclusively even 
when it is markedly developed. . In this I am opposed to Hauser, Kraushaar, 
Ganghofner and Thiemich, who believe that a very intense result of palpation 
of the ansa facialis is a positive sign of latent tetany. 

The mouth phenomenon, first described by Loos and Escherich, is to be 
considered in a manner similar to the facial phenomenon. Loos understands 
by this a lightning-like contraction of the angle of the mouth upon the side 
opposite to that of the palpated facial nerve, Escherich a contraction of the 
upper lip in sleeping children after percussion in the course of the constrictor 
muscle of the mouth, whereby the lips are protruded as in the act of whistling, 
Thiemich a rapid contraction of the orbicularis oris in children while awake 
when some point upon the upper lip is irritated mechanically (fish-mouth) . It 
is evident that these three phenomena are only the expressions of a special 
liyperirritability of the facial nerve which innervates the orbicularis oris. In 
my opinion they are of no positive diagnostic value in infantile tetany, as they 
may also be produced in normal children who possess over-sensitive nerves of 
the face. 

Less common and distinct is the hyperirritability of other nerve trunks. 
It may be recognized in the extremities by a lightning-like contraction of the 



VARIETIES OF INFANTILE CONVULSIONS 427 

muscles supplied by the nerve in question when the nerve trunks are tapped 
with a percussion hammer. This may be tested most readily by percussion of 
the radial nerve where it curves in the lower third of the upper arm, and in 
the peroneal nerve which is stimulated externally from the head of the fibula 
by tapping lightly with the percussion hammer. 

Lightning-like dorsal flexion of the hand results from mechanical irritation 
of the radial nerve; abduction and slight dorsal flexion of the foot by per- 
cussion of the peroneal nerve ; but that these phenomena also occur in patients 
free of tetany and even in entirely normal children is even more true than of 
the facial phenomenon. 

Of great importance in the latent and in the manifest tetany of infancy, 
just as in later life, are the changes of electric contractility. As was clearly 
shown by Kussmaul in 1872, and by Erb in 1874 and 1879, there is an m- 
creased irritability of the motor nerves to both currents. But faradic hyper- 
irritability plays only a secondary role ; the principal part, particularly in chil- 
dren, is assumed by the changes of galvanic contractility. We shall concern 
ourselves exclusively with the latter. 

The electric examination should be undertaken in early infancy, as in older 
individuals, with Stintzing's normal electrode and without anesthesia, an elec- 
trode of 50 c. cm. serving as the negative pole. To gain uniform results for 
comparison it is very serviceable to employ the products of investigation of the 
median nerve, which is stimulated at the distal end of the sulcus bicipitalis in- 
ternus. In regard to the normal contractile relations Mann has determined, 
analogous to the findings of C. and A. Westphal, that the sensitiveness of the 
motor nerve is less until about the eighth week of life than later, and that 
from this period to the end of the second year great variations occur which are 
not parallel to normal relations at the same age. 

Nevertheless the contractility of advanced age is not reached in the first 
years of life; on the contrary, the values are always greater than in adults. 
Mann, who examined 13 children under eight weeks of age and 43 older chil- 
dren with the galvanic current, found that the normal value for CaCC of the 
median nerve in normal children from the third to the thirtieth month is al- 
most invariably between 0.7 and 2.0 milliamperes, while in adults, according 
to Stintzing, the corresponding value is 0.3 to 1.5 Ma. 

Of great influence upon the contractility, according to Mann, is the nutri- 
tive condition of the child, for with a profuse adipose tissue stronger currents 
are necessary to produce a minimal contraction than with a thin cutaneous 
covering. 

As Escherich determined, the values for CaCC which are characteristic of 
later life are subject to special variations in the first years and Thiemich has 
since stated that they are not decisive in all cases for the diagnosis of tetany. 

Thiemich has rendered valuable service by demonstrating that in the CaOC 
a much more certain criterion exists for determining the presence of galvanic 
hyperirritability than was formerly the case in testing with CaCC. 

In the tetany of adults the production of CaCC and of CaCT with relatively 



428 CONVULSIONS IN CHILDREN 

mild currents is well known. These conditions were also studied in the great 
nerve trunks in small children by Escherich, Ganghofner, Hauser, Thiemich, 
and Mann. In the main the first three authors found similar anomalies of 
contractility in infantile tetany, while Thiemich and Mann were able to demon- 
strate that the early appearance of CaCT is not so important ; on the contrary 
that the most important deviation from the usual contractile condition could 
be determined by CaOC. According to these authors a medium value under 
normal conditions for the last-named phase of contraction of the median nerve 
is 8.22 Ma. In latent tetany this average is diminished to 2.23 Ma. and in 
manifest tetany to 1.94 Ma. 

As a limit between the CaOC of normal conditions and of tetany Thiemich 
and Mann have given the figure of 5 Ma. Values below 5 Ma. belong exclu- 
sively to tetany, values above 5 Ma. are always normal. Thiemich has gone 
further and upon the basis of this limitation in electric contractility of the 
motor nerves has attempted to divide the spasmodic phenomena of early infancy 
into two groups, whereby CaOC below 5 Ma. indicates a tetanoid condition, that 
is, is characteristic of latent tetany, while figures over 5 Ma. for CaOC indicate 
normal contraction of the peripheral nerves. 

Ganghofner has failed repeatedly to demonstrate the figures given by Thie- 
mich for CaOC in genuine tetany and is therefore not inclined to ascribe to 
them the diagnostic importance which is given by Thiemich. In fact he 
denies that the galvanic hyperirritability is of special significance in the diag- 
nosis of latent tetany and believes that a sufficient support for the diagnosis of 
latent tetany is given by the presence of an especially increased mechanical 
irritability. 

The values obtained by Escherich in testing the nerves of the face for CaCT 
in tetanic children under anesthesia cannot be utilized in practice because it 
is not always possible to make a galvano-diagnostic examination under anesthe- 
sia and the employment of stronger currents without narcosis causes an active 
tetanic spasm of the muscles of the face in consequence of the pain, which may 
simulate CaCT. However, it is necessary to emphasize that Escherich, aided 
by v. Wagner, was the first to demonstrate a measurable increase of galvanic 
contractility in infantile tetany by means of CaCT, that in the affected chil- 
dren this reaction appears with 5.2 and even with 1 Ma., while in normal chil- 
dren CaCT cannot be produced with currents of 20 Ma. and more. Escherich 
and Hauser assume a pathologic increase of electric contractility for CaCC 
when this occurs in the peroneal and ulnar nerves under less than 0.3 Ma., and 
in the facial nerve under 1 Ma. 

In this connection two symptoms of tetany, recently described by Peters, 
must be mentioned, of which one, the " jumping-jaeh phenomenon/' presents 
a special variation of electric hyperirritability, and the second consists of 
increased values for pressure and amount of the cerebrospinal fluid in lumbar 
puncture. 

The first-named symptom is described as follows : Upon galvanization of 
the spinal cord at the cervical and lumbar enlargements, with the cathode upon 



VARIETIES OF INFANTILE CONVULSIONS 429 

the vertebral column, the anode upon the breast, severe and rapid contractions 
appear in the upper and lower extremities which actively resemble the move- 
ments of a jumping- jack. This muscle play occurs in infantile tetany with 

3 to 4 Ma., while in normal children two or three times the amount of current 
is necessary to produce the condition. 

Hoffmann also assumed the presence of a reflex hyperirritability and a 
genuine hyperirritability of the sensory nerves in tetany in addition to the 
legitimate symptom triad which has already been mentioned. As a sign of this 
sensory hyperirritability the appearance of Trousseau's contracture following 
cutaneous irritation, for example, after the prick of a needle, after raising a 
fold of the skin, or after percussion on the vertebral column, has been reported. 
As for myself, however, I have not succeeded in producing Trousseau's contrac- 
tion in infantile tetany otherwise than by constricting the upper arm. 

The symptom triad — spontaneous or artificially-produced tonic spasms of 
the extremities, increased mechanical and galvanic contractility (Trousseau's, 
Chvostek's, and Erb's phenomena) — is characteristic of tetany at all periods of 
life. Through the investigations of Loos and Escherich in the ninth decade 
of the last century the teaching of tetany of children has included a relation- 
ship of that affection with spasm of the glottis and idiopathic eclampsia. These 
authors found that many children who suffered from such forms of spasm 
showed symptoms of tetany, namely, an increased mechanical and to some ex- 
tent also an increased galvanic irritability of the peripheral nerves. They 
accordingly declared laryngospasm, and eclampsia occurring with laryngo- 
spasm, to be tetany, but generalized so far as to regard laryngospasm only as 
a part phenomenon of infantile tetany. Loos, in contrast to Kassowitz, at first 
denied all connection of these spasmodic conditions with rachitis. 

The priority of discovery of the association of certain cases of laryngospasm 
with tetanic symptoms belongs to the London physician Gay, who, in 1890, 
published in the journal " Brain " an article upon spasm of the glottis. Gay 
reported that he found the facial phenomenon in 64 children, of whom 47 suf- 
fered with spasm of the glottis, 9 with general convulsions, 7 with genuine 
tetany, and 1 with spasmus nutans. Of these 64 children 54 had positive and 

4 questionable symptoms of rickets. He therefore arrived at the conclusion 
that laryngospasm and tetany bore a certain relation to each other and were 
in some manner associated with rachitis. 

The opinion of Loos and Escherich that laryngospasm is always a partial 
phenomenon of infantile tetany was rejected by most authors who afterward 
concerned themselves with this question, since it was determined by many that 
laryngospasm occurred quite frequently without other symptoms of tetany. 

Upon comparison of various statistics regarding spasm of the glottis Kirch- 
gasser found that this condition is almost twice as common as tetany and that 
it is associated with latent symptoms of tetany in barely 25 per cent, of the 
cases. 

The exceedingly comprehensive compilation of the reports of different 
authors relative to spasm of the glottis and tetany, published by d'Espine in 



430 CONVULSIONS IN CHILDREN 

1902, shows that the former condition is almost always much more common 
than tetany and that the genuine tetany corresponding to the affection in adults 
is almost unknown in certain regions, for example, in Geneva, Turin, Toulouse, 
and Munich. Of special interest are the conditions found in Geneva, con- 
cerning which d'Espine from his own observation reports that among 5447 
children observed in his dispensary in a decade he has seen only 2 cases of 
actual tetany, 54 cases of eclampsia, and 20 cases of spasm of the glottis. 

In the years 1899 to 1901 I carefully examined 82 cases of spasm of the 
glottis for symptoms of tetany and found that only 17 cases, therefore about 
one-fifth, were associated with genuine tetany in our sense of the term. 

An article upon infantile tetany which Boral published in 1893, including 
121 cases of spasm of the glottis from my hospital, showed that only in 13 were 
there symptoms of well-marked tetany, either spontaneous spasms or Trous- 
seau's phenomenon. In addition to these the facial phenomenon was quite 
commonly observed in laryngospastic children. Altogether Boral found the 
facial phenomenon in 1G9 cases, frequently with laryngospasm but often inde- 
pendently of it and of other symptoms of tetany. In 24 cases Trousseau's phe- 
nomenon could be demonstrated simultaneously and in 14 of these there were 
respiratory spasms, in 21 the facial phenomenon. 

The previously mentioned cases in my department, as well as those re- 
ported by Boral and those collected by myself for d'Espine's report at the Con- 
gress at Toulouse (1902), were not subjected to a thorough galvano-diagnostic 
test. Since Thiemich's report Dr. A. Schuller and myself examined many 
children from the neurological department of our hospital, who suffered from 
laryngospasm and eclampsia and presented the facial phenomenon, with the 
galvanic current, but were not always able to arrive at the figures for CaOC 
which were given as characteristic of latent tetany by Thiemich. This shows 
that mechanical and electrical hyperirritability of infants is by no means al- 
ways the same. 

Japha, who investigated more than 150 cases of laryngospasm in H. Neu- 
mann's Clinic in Berlin galvano-diagnostically, has reached the conclusion that 
in 80 to 90 per cent, of such children galvanic hyperirritability is present in the 
Thiemich-M&nn sense. Among the 167 children examined there were many 
in whom spasm of the glottis was recognized by a simple " sighing " or " suck- 
ing " during cr}dng or excitement. 

This relation between laryngospasm and the Thiemich-Mann reaction, how- 
ever, loses in importance by the simultaneous report of Japha that 53 cases 
among 304 children examined, who were free from laryngospasm and mechani- 
cal hyperirritability of the nervous system, some of them over three years of 
age, revealed an increased galvanic irritability in the Thiemich-Mann sense. 
These children were always nervous or otherwise sickly. Perfectly normal 
children never showed this irritability. 

These reports of Japha coincide with my observations in my article on 
the Myotonia of Nurslings regarding the findings in older children. In them 
also, although not employing the new method which was used by Thiemich and 



VARIETIES OF INFANTILE CONVULSIONS 431 

Japha, I repeatedly demonstrated a galvanic hyperirritability of the peripheral 
nerves (CaCC below 1 Ma. in the facial nerve) in the absence of any other 
symptom of tetany than the facial phenomenon, and to this I do not by any 
means attach the importance of a positive symptom of latent tetany. Finkel- 
stein also, as we shall hear later, has very frequently found the Thiemich-Mann 
reaction in older artificially-nourished infants who did not present the slightest 
indication of any other hypersensitive condition. 

Instead of concluding from this that there are children free of tetany who 
show the Thiemich-Mann reaction, and of placing this kind of galvanic hyper- 
irritability in early childhood upon a different plane from that of the tetany 
of adults, children without other tetanic symptoms who presented the Thie- 
mich-Mann reaction were declared to be the subjects of tetany and were sup- 
posed to possess a tendency to laryngospasm. The important fact in this is 
that a number of cases examined by Japha who showed the Thiemich-Mann 
galvanic hyperirritability without other symptoms of tetany were over three 
years of age. At this age, according to my experience at least, the tendency to 
spasm of the glottis has disappeared. Children who have not been affected by 
that condition before the end of the first year of life are not subject to it later. 

Before investigating the individual symptoms which are associated with 
tetany, in regard to their actual relation to this spasmodic neurosis, a positive 
standpoint must be established, which culminates in the fact that there is no 
separate division for the tetany of infancy, and that even in childhood we may 
only refer to this affection when the above-mentioned symptom triad is pres- 
ent: spontaneous or artificially-produced spasm of the extremities with dis- 
tinctly demonstrable galvanic and mechanical hyperirritability of the motor 
nerves. In my opinion the difference between manifest and latent tetany, 
even in infancy, is that in the former spontaneous spasms of the extremities 
occur, and in the latter only spasms artificially produced. Latent tetany, how- 
ever, may at any moment become the manifest form of the disease. 

Here, as was previously indicated, we are opposed to most modern authors, 
among whom, however, there is no unanimity in regard to the conception of 
latent tetany. 

Ganghofner has divided the symptoms of infantile tetany which are present 
in the interval free from attacks into obligatory and facultative latent phenom- 
ena, and to an especially increased mechanical irritability and to Trousseau's 
phenomenon he has attached the importance of obligatory latent symptoms. 
Spasm of the glottis and eclamptic conditions he has declared to be facultative 
latent phenomena of tetania infantilis. 

Thiemich, on the other hand, attaches principal importance to the galvanic 
contractility which results from the cathodal opening contraction (CaOC below 
5 Ma.). 

Escherich, again, has regarded all forms of spasm occurring in rachitics 
which run their course with general hyperirritability as the " tetany of ra- 
chitics." 

I maintain that the diagnosis of tetany in infancy cannot be considered 



432 CONVULSIONS IN CHILDREN 

from other viewpoints than those which predominate at other periods of life. 
The only positive criterion of latent tetany is the possibility of artificial pro- 
vocation of a spasmodic condition analogous to a tetanic seizure. Mechanical 
hyperirritability of the nerve trunks occurs in infancy without Trousseau's 
convulsion, as we have already seen, and this is also true of those children who 
possess an increased galvanic irritability. 

These circumstances are not altered by the fact that the tetany of children 
in its etiologic aspect must be regarded from another standpoint than that of 
adults, because, like all other forms of spasm dependent upon hyperirritability, 
in early infancy it is in intimate relation to a disease which is foreign to ad- 
vanced age, namely, rachitis. 

Therefore, while it is certain that in a great number of cases of laryngo- 
spasm the facial phenomenon and Erb's or the Thiemich-Mann symptom is 
present, the view is by no means justified that all cases of spasm of the glottis 
are tetany; on the contrary, it only demonstrates that numerous rachitics suffer 
from symptoms of a hyperirritable nervous sphere. 

It has been several times reiterated in regard to the facial phenomenon that 
undoubtedly quite a number of children who suffer from laryngospastic attacks 
do not present this sign and it is necessary to add that the facial phenomenon 
no longer is of decisive importance in the diagnosis of tetany. During this 
period of life it is found in hysteria, in night-terrors, and also in children 
who are merely anemic. It is a symptom of a hyperirritable nervous sphere 
and is not necessarily associated with tetany. Kraepelin and I were able to 
demonstrate Chvostek's phenomenon in myxedema, and I found it in mon- 
golism. Loos, H. Schlesinger and Escherich noted it in children free from 
tetany but otherwise sickly. Frankl-Hochwart saw it in 4 per cent, of normal 
children. 

There are severe cases of rickets in which repeated attacks of apnea have 
occurred but never the facial phenomenon nor an increase of galvanic irrita- 
bility in Thiemich's sense. Children of this kind show a conspicuous tetanic 
rigidity over the entire body during the attacks of apnea, wherein the hands 
present a spasmodic closure of the fingers. Nevertheless in the intervals free 
from attack these children do not show the characteristic contraction of the 
hand of tetany inasmuch as Trousseau's symptom cannot be produced arti- 
ficially. 

In my opinion galvanic hyperirritability in infancy, and particularly the 
Thiemich-Mann reaction of the peripheral nerves, is of somewhat different 
importance than in later life. Above all, it is noted with great frequency in 
psychically hypersensitive rachitic children who suffer from the convulsions 
previously designated as idiopathic; further, as was shown by the investiga- 
tions of Finkelstein and Japha, in nurslings who are otherwise normal under 
the influence of certain deleterious alimentary effects which arise from nutri- 
tion with cow's milk; thirdly, as was found by Japha and myself, galvanic 
hyperirritability is present in children who, beyond the age of rachitis, are 
free from rickets, free from hyperirritability convulsions and also free of those 



VARIETIES OF INFANTILE CONVULSIONS 433 

alimentary difficulties which are supposed to be due to nourishment with cow's 
milk in infancy. Under such circumstances it is necessary to seriously con- 
sider whether it is permissible to regard this as an obligatory symptom of 
latent tetany in infancy, or whether, on the contrary, it belongs to the special 
peculiarities of early infancy, showing its effect in various general disturbances 
by a hyperirritability of the central nervous system which can be demonstrated 
in a measurable manner by the reaction of the motor nerves to the galvanic 
current. 

Here, in my opinion, the conditions are different from tetany of adults. I 
do not know whether a modern neurologist would designate a person presenting 
galvanic hyperirritability, without other symptoms of tetany, especially with- 
out Trousseau's sign, as a subject of latent tetany ; but this much is certain, if 
an adult has manifest tetany he also presents galvanic hyperirritability. If 
the history of tetany is investigated it will be found that the mechanical hyper- 
irritability of the peripheral nerves was the particular reason for Erb's attempt 
by galvanic methods to bring this hyperirritability into a definite numerical 
relation. If it is true that a great number of children in the first years of life, 
under various conditions — in consequence of rickets, of improper nutrition, of 
other debilitating influences upon the nervous system — present this galvanic 
hyperirritability which in later life is found only in tetany, a knowledge of this 
fact is necessary, but all of these children need not be designated as candidates 
for tetany or as the subjects of latent tetany. On the contrary, galvanic hyper- 
irritability is to be regarded only as a part phenomenon of that general hyper- 
irritability of the nervous system of infants which is due in the first years 
particularly to the rapid growth of the brain. 

In my opinion the same sharp limits should be extended to the conception 
of tetany in infancy which obtain in the special pathology for the later periods 
of life; without Trousseau's symptom or carpopedal spasms no diagnosis of 
tetany; but we must again insist that mechanical and galvanic hyperirritability 
of the motor nerves is never absent in infantile tetany. 

The conceptions and terms " spasm of the glottis " and " eclampsia " of 
infancy must be retained as substantive designations for definite forms of con- 
vulsion, just as the conception of tetany, in which, however, they are not to be 
included. In addition we must always bear in mind that these three varieties 
of spasm may occur simultaneously in the same individual. 

Mechanical and galvanic hyperirritability is always present in tetany, sensu 
strictiori, but is inconstant although very common in simple spasm of the 
glottis and in eclamptic convulsions — briefly, in all of those affections which we 
have learned to recognize as hypersensitive conditions of the first years of in- 
fancy. 

The fact that the definition of tetany is viewed in various ways by different 
authors is a great drawback in determining the frequency and the occurrence of 
tetany in infancy and in the utilization of reports. Anyone, like ourselves, 
who only regards those cases as tetany in which characteristic tonic spasms 
exist in the extremities will find that tetany is a relatively rare affection, some- 
29 



434 CONVULSIONS IN CHILDREN 

what more frequent in certain regions, than in others, just as is the tetany of 
adults. On the other hand, those who include the entire group of hyperirrita- 
bility convulsions and in addition all children who present galvanic and me- 
chanical hyperirritability of the motor nerves in tetany will find much greater 
figures. Thus, according to the unanimous reports, genuine tetany is a rare 
disease in Switzerland and in France, while laryngospasm and eclampsia are 
no less frequent there than elsewhere. 

Great variations in the figures of tetany of two observers in the same city 
can only arise from a different conception of the disease. Thus, Heubner found 
only 3 cases of tetany among 17,000 sick children in Berlin; Baginsky, in the 
same city and during the same time, 143 cases among 25,000 children. 

In addition to the designation " latent tetany " the term " tetanoid condi- 
tion " has been invoked for a number of cases which present symptoms of hy- 
perirritability of the nervous sphere. Escherich refers to a tetanoid condition 
in children who show laryngospasm and the facial phenomenon. Thiemich 
has lately attempted, in a French publication, to differentiate the convulsions 
occurring in infancy, according to the galvanic reaction, into those with and 
without the tetanoid condition. This author, however, must admit that there 
is no difference in the manner in which the spasm presents itself in hypersen- 
sitive children with a tetanoid reaction and in those with a normal galvanic 
irritability. 

The expression "tetanoid condition/ 7 to designate children with a hyper- 
irritable galvanic or mechanical reaction does not seem fortunately chosen, be- 
cause it does not cover the conception which the author of this term, v. Frankl- 
Hochwart, understood by it. v. Frankl-Hochwart designated as a tetanoid 
condition the occurrence of Trousseau's phenomenon and paresthesias in the 
hands and fingers in tetanic patients during the interval free from attacks. 

If the term " tetanoid " were to be employed in another sense in infancy it 
would be necessary to refer expressly to a " tetanoid condition of children," 
which is not synonymous with the tetanoid condition of adults. I believe it is 
advisable not to extend the conception of the tetanoid condition so far as was 
done by Escherich and Thiemich, but simply to refer to hyperirritable children 
— a designation which is certainly not prejudicial. 

Genuine tetany of infancy, in regard to its appearance, is largely the same 
as in adults. There can be no doubt that here also epidemic conditions pre- 
vail. There are large cities in which the picture of genuine tetany in nurslings 
and children is unknown, and Hecker, of Munich, has reported in the Volk- 
mann collection, in regard to the tetany of children in his city, that his con- 
clusions were derived principally from the study of the literature and not from 
his own observations. The tetany of older children differs neither etiologically 
nor clinically from that of adults. 

No other form of hyperirritability convulsions of young children is so asso- 
ciated with season as is genuine tetany. According to my careful investigations 
it is present in Vienna in the late winter and spring exclusively, and herq 
again there is a more cumulative appearance of tetany cases within the desig- 



VARIETIES OF INFANTILE CONVULSIONS 435 

nated months in certain years, as in 1899 and 1900, than during the same 
months of other years, as in 1902 and 1903 when there was a remarkable de- 
crease in their number. 

The other forms of hyperirritability convulsions — laryngospasm and 
eclamptic attacks — are forms of hyperkinesia of young children which occur 
everywhere and in every season of the year, although more frequently in the 
late winter and spring. The) therefore possess a certain relationship with 
tetany without being analogous conditions. 

D. SPASM OF THE HEAD AND EYES IX CHILDREN : SPASMUS NUTANS AND 

NYSTAGMUS 

These two functional spasms of children must be considered together, as 
they are always associated in infancy and are also combined genetically. As a 
rule nodding spasms appear at an earlier age than tremor of the eyes and very 
often disappear before the latter condition so that spasm of the eyes occasionally 
is present alone for a limited time. 

Both forms of spasm occur as part phenomena of organic affections of the 
brain, and in adults and older children are also observed in epilepsy (Lange). 
These spasms, occurring in the first three years of life, are almost exclusively to 
be regarded as functional neuroses, which, like laryngospasm, eclampsia, and 
tetany, are associated with general hyperirritability of the nervous sphere. 

Spasmus nutans is a form of spasm of purely functional nature peculiar 
to the first three years of life, which was first described in 1850 by Henoch and 
Eomberg, but awakened greater interest among pediatrists after the minute in- 
vestigations by Kassowitz, Lange, and Eaudnitz. 

The following is a brief description of the condition : 

The affected children show a peculiar shaking of the head, either in a verti- 
cal direction, in the form of nodding or ooiving movements, whence the names 
nodding and salaam spasm; or the head wobbles from side to side or performs 
rotary movements in the atlanto-occipital joint. Certain children, while awake, 
show one or another variety of this spasm continuously, others are affected 
periodically. According to Eaudnitz the shaking or rotary movements are not 
particularly rapid, at most with the rapidity of the seconds pendulum. Here 
the lightning-like appearance which is characteristic of the clonic convulsions 
of the muscles of the extremities in children, together with loss of conscious- 
ness, is entirely lacking. In the affection under discussion consciousness is al- 
ways retained. The shaking movements generally disappear when the child 
is unobserved and in complete repose. With intended movement or upon 
attempts to fix certain objects, or under psychical irritation, the spasmodic 
movements of the head become more severe and as a rule the first excursus at 
the onset of an attack is more rapid and complete than those which follow. 

So far as I have been able to determine the affection does not develop sud- 
denly, but very gradually, the head now and then wobbling to and fro with an 
erect position of the body. In most cases but little attention is given to the 
affection at its onset. The first attacks consist of a few swaying motions of the 



436 CONVULSIONS IN CHILDREN 

head, lasting scarcely a minute, which are supposed by those about the patient 
to be intended or the signs of an especially pleasant or painful stimulation. 
In time, however, these movements become more severe, prolonged, and recur 
several times daily, particularly under excitement. Usually importance is not 
attached to the case until the attacks occur more frequently and are more pro- 
longed. 

In the majority of instances the nodding spasm is associated with tremor of 
the eyes (nystagmus). 

This form of spasm consists of clonic contractions in the course of the 
ocular muscles in rapid sequence. The excursions may be so rapid that we 
might actually speak of tremor of the bulbi. The contraction of the eyes 
occurs in various directions according to the nature of the predominant con- 
tracting muscles. It may be either in the vertical or in the horizontal plane, 
or occur in both directions alternately. In addition to the permanent tremor 
there may also be a rapid to-and-fro movement of the bulbi. Severe cases of 
spasmus nutans are always associated with nystagmus; only in the stage of 
onset, as a rule, is tremor of the eyes absent. In some cases nystagmus is the 
chief symptom of the combined convulsive category under consideration and 
becomes continuous, while nodding and bowing spasms occur in transitory 
and very brief attacks. In other cases the child is attacked by nystagmus as 
soon as its attention is fixed, while the shaking of the head appears only when 
there is simultaneous excitement. Upon close questioning I was able to deter- 
mine that nodding spasm had previously been present even in those cases of 
nystagmus which were unaccompanied by the phenomenon at the time of ex- 
amination. Nystagmus is not always developed equally in both eyes. 

Both forms of spasm disappear during sleep. In. the waking hours many 
children show both varieties of spasm uninterruptedly or broken by very short 
pauses. Often, while recumbent, the child only shows nystagmus, but as soon 
as the head is raised or the body brought into a vertical position spasmus 
nutans appears. In all cases the movements of both the head and the eyes are 
increased by psychic stimulation. These varieties of spasm run a favorable 
course in infancy provided they are pure functional neuroses. The spasmodic 
condition disappears during the third or fourth year of life without resulting 
mental disturbance, paralysis or contractures, provided the underlying affec- 
tion, rachitis, is recognized and treatment by phosphorus instituted. 

In regard to the development of these spasmodic affections it must be re- 
marked that children with nodding spasm and nystagmus always present other 
symptoms of a hyperirritable nervous sphere, as do those who suffer from 
spasm of the glottis and eclampsia. 

Furthermore, I have found, in quite a number of cases of spasmus nutans, 
that the affected child suffers simultaneously from the two last-named condi- 
tions. 

Among our cases, which include more than 50 children with spasms of the 
head and eyes, we have never failed to find rachitic changes in the skeleton, 
so that it appears necessary to include spasmus nutans and nystagmus in the 



VARIETIES OF INFANTILE CONVULSIONS 437 

category of hyperirritability convulsions of infancy associated with rachitis. 
Here we must not entirely ignore the view of Raudnitz that over-exertion of the 
muscles of the eye, as the result of insufficient or bilateral light, plays a certain 
role in the occurrence of these forms of spasm similar to that in the nystagmus 
of miners. 

It is easy to concede that in hypersensitive children who are at the age of 
most intense growth of the brain, those ganglion groups and conduction tracts 
become particularly irritable which are exposed to special exertion. 

Accordingly we would then be dealing with a functional hyperexertion, es- 
pecially an increased irritability of certain cerebral motor nerves (ocular nerves 
and spinal accessory). 

Analogous to the assumption of Kassowitz of a cortical origin of spasm 
of the glottis, Stamm has demonstrated that in nodding spasm and in nystag- 
mus of children we are concerned with a mechanical irritation of certain por- 
tions of the cerebral cortex due to hyperemia of the internal periosteum of the 
skull resulting from rachitis. In any event the predilection of age between six 
months and three years, the never-failing rachitis, the constant psychical hyper- 
sensitiveness, and the association with other spasms of excessive irritability, 
make it reasonable to include also the nodding spasms of children in the realm 
of hyperirritability convulsions. 

Supplemental to the foregoing, it must be mentioned that cataleptic phe- 
nomena have been repeatedly observed in rachitic children without organic 
disease of the central nervous s} T stem. To Epstein is due the credit of first 
remarking these conditions, which I am in a position to confirm. Here we are 
concerned with markedly rachitic nurslings who present the most grotesque 
positions of the extremities, which are retained for minutes if the limbs are 
passively arranged, and are only gradually replaced by a normal attitude. I 
saw a child of this category, aged nine months, who presented cataleptic rig- 
idity of the extremities in addition to laryngospasm, nodding spasm and nys- 
tagmus. In this case a lower limb which was completely extended at the knee- 
joint and flexed at a right angle at the hip- joint, remained for minutes in this 
position — an absolutely unnatural one which can be maintained voluntarily 
only with the greatest difficulty. 



ETIOLOGY OF HYPERIRRITABILITY SPASMS 

In turning to the etiology of hyperirritability convulsions of infancy it is 
first necessary to emphasize that in my opinion rachitis is the connecting link 
for all of the forms of spasm dependent upon general hyper sensitiveness of the 
nervous sphere. This affection has never been absent in any of the cases under 
consideration. This view, already approached by Elsasser and Gay, and in 
recent times warmly advocated by Kassowitz and his pupils and also by Esch- 
erich, is opposed to a second theory, according to which the spasms here under 



438 CONVULSIONS IN CHILDREN 

discussion, or the hyperirritability which is the foundation of them, are due 
to alimentary damage and are primarily dependent upon g astro-intestinal auto- 
intoxication. A number of authors, particularly Comby and D'Espine, have 
gone further, in that they regard g astro-intestinal auto-intoxication as the com- 
mon cause of rickets as well as of the hyperirritable conditions of infancy. 
Others, again, have entirely ignored a relation between rickets and hyperirrita- 
bility convulsions and have declared the occurrence of the latter with rickets to 
by an accidental combination, and that the spasms alone are disturbances of the 
nervous sphere due to alimentary damage. . 

In my opinion weighty factors oppose the generalization of auto-intoxica- 
tion as the etiologic principle of hyperirritable conditions and spasms in in- 
fants. We may conceive that, in acute digestive disturbances, with the en- 
trance of the enterogenous poison into the circulation an irritation of the cen- 
tral nervous system arises which shows itself by intermittent clonic spasms. 
It is also conceivable that in chronic digestive disturbances the toxic sub- 
stances formed and absorbed in the intestinal canal give rise to intermittent 
spasmodic conditions as often as an intense over-flooding of the organs with 
toxic products arises. Again, it is possible that under certain conditions per- 
sistent tonic, not intermittent spasmodic, conditions may occur from the con- 
tinued absorption of intestinal poisons into the circulation in chronic auto- 
intoxication. 

The best example of this form of autotoxic-spasmogenic action is the pre- 
viously described myotonia perstans of nurslings in severe intestinal affections. 
The autotoxic spasmodic conditions just mentioned are controlled by the pres- 
ence of a demonstrable and recognizable intestinal disturbance leading to auto- 
intoxication, and therefore exist for a relatively limited time, disappearing 
when no more toxic products are produced from the gastrointestinal tract, as 
has already been carefully explained in the discussion of occasional convulsions 
of childhood. 

It is rather remarkable that, in those children particularly who surfer from 
authentic spasmodic conditions of gastro-intestinal origin dependent upon en- 
dogenous toxin formation within the intestinal canal, a permanent hyperirrita- 
bility of the nervous sphere in the sense of our previous explanation is only 
demonstrable when the children were over-sensitive from birth, and, naturally, 
are also occasionally affected by the characteristic spasms of an intestinal affec- 
tion. 

Children of the last category for many months, occasionally for years, suffer 
from a hypersensitive nervous sphere which is characterized by permanent 
demonstrable symptoms and especially by intermittent respiratory spasms. 

If the hyperirritability which is the basis of these spasms is made dependent 
upon gastro-intestinal auto-intoxication, then the spasms in these cases must 
last for months, and could only be due to chronic diseases of the chylopoietic 
system or from a continued deficiency of the intermediary metabolism. But 
it must be stated emphatically that disturbances of the last-mentioned nature 
are demonstrable only in a very small fractional proportion of hyperirritable 



VARIETIES OF INFANTILE CONVULSIONS 439 

infants, while, inversely, hyperirritable conditions, especially laryngospasm and 
eclampsia, also occur in healthy breast-fed children who do not suffer from in- 
testinal disease, and those who are decidedly atrophic almost never show such 
hyperirritable and spasmodic conditions. Further, if breast-fed children suffer 
from a general hyperirritability of the nervous system this certainly does not 
occur during the time in which the appearance of intestinal intoxication could 
be most readily explained — during the period of weaning ; on the contrary, its 
first appearance is much earlier, about the fifth or sixth month, and, as has 
been already explained, in the form of characteristic respiratory spasm in psy- 
chical irritation. Such children, however, are never free from rickets. The 
reason why hyperirritable conditions are almost never observed in atrophic chil- 
dren is based upon their lesser predisposition to rachitis. 

Children who present the hyperirritable and spasmodic conditions under 
discussion are usually well-nourished and have a considerable amount of adi- 
pose tissue. Aside from rickets they usually deviate from the normal only by a 
moderate pallor of the skin and slight puffiness of the face. But I have ob- 
served these pathologic conditions also in splendidly nourished children of 
good color, although always in breast-fed children suffering from rachitis. 

On the basis of electric investigation of the motor nerves Thiemich, Gregor 
and Finkelstein attempted to refer the hypersensitiveness of nurslings, and 
with this also the so-called infantile spasms, to the nutrition. 

Thiemich emphasized that the galvanic irritability of the motor nerves in 
one and the same child is subject to great modifications, as Gregor has shown, 
under the influence of nourishment. Thiemich also pointed out that, in arti- 
ficially-nourished children who suffer from constipation, by emptying the in- 
testinal tract or by the institution of a simple water diet the galvanic hyper- 
irritability previously present may be decidedly decreased, and that the change 
to natural food prevents its recurrence. From this may be deduced important 
conclusions for treatment, which primarily concern the intestinal canal as the 
point of attack. Finkelstein has reached similar results and has attached to 
artificial nutrition with cow's m ilk sl predominant importance in the occurrence 
of the tetanoid condition. Thus, upon the basis of electric investigation, the 
old views promulgated by Flesch and Eehn, and recently again made prominent 
by Fischbein, were revived, which required as curative measures for spasm of 
the glottis and eclampsia in artificially-nourished children a change of food 
and a return to breast milk. Finkelstein, in particular, believed that from the 
whey of cow's milk the elements responsible for the hyperirritability reached 
the circulation of the nursling, to which Thiemich responded that he was able 
to demonstrate galvanic hyperirritability in children who had never taken a 
drop of cow's milk, but in addition to breast nourishment had been fed with 
starchy substances. 

Although I am not in a position to confirm the connection between Thie- 
mich's tetanoid condition and galvanic hyperirritability and artificial nutri- 
tion, as I have not investigated these relations, nevertheless, the fact is certain 
that eclampsia and laryngospasm are very common in breast-fed children and 



440 CONVULSIONS IN CHILDREN 

are much less frequent in those who are artificially nourished. If nourishment 
with cow's milk, or the addition of a few biscuits and some flour soup to breast 
milk were capable of producing a tetanoid condition in an infant it would be 
difficult to explain why so many artificially-nourished children are permanently 
free of hyperirritability convulsions. 

In view of these circumstances the question is justified, whether the pres- 
ence of galvanic hyperirritability in the Thiemich-Mann sense may be identi- 
fied only in early childhood with the " tetanoid condition " or with " latent 
tetany.'' 

If it is true that nutrition with cow's milk and other alimentary deleterious 
agents which provoke the reaction of the peripheral nerves in the nursling, 
produce a tetanoid condition, there would be a disagreement between the time 
of appearance of the hyperirritability convulsions and of galvanic hyperirrita- 
bility. The alimentary damage in artificial nutrition would have to be princi- 
pally operative in the warm seasons. Accordingly, galvanically hyperirritable 
children should be found most frequently in mid-summer and in the autumn. 
At this season of the year, however, the so-called idiopathic convulsions of in- 
fancy are least frequent, while children are most commonly attacked by tetany, 
laryngospasm, and eclampsia in the late winter and spring. From this it ap- 
pears that too far-reaching conclusions should not be constructed in regard to 
a connection of galvanic hyperirritability in early childhood with idiopathic 
infantile convulsions. 

There is another factor in opposition to the supposed spasmodic effect of 
cow's milk. Psychical hypersensitiveness of children usually disappears at a 
time during which cow's milk is the principal nutriment — in the latter half 
of the second year, or at least much earlier than the beginning of a diet defi- 
cient in cow's milk, similar to the food of an adult. These conditions disap- 
pear, rapidly and independently of nutrition, under the influence of treatment 
with phosphorus, or when the rachitis improves spontaneously. This expe- 
rience, confirmed in thousands of cases in our Clinic in Vienna, is alone suffi- 
cient to deprive the alimentary theory of hyperirritability spasms of infancy 
of all support. Anyone familiar with the conditions under which children of 
the lower classes develop and who must concern himself with such children 
professionally, knows that advice to patients of that kind in regard to a change 
of food is of exceedingly problematic value. If, notwithstanding this, the ad- 
ministration of phosphorus has a constant and occasionally even miraculous 
effect in these hyperirritability convulsions, the excessive excitability which is 
the cause of them must be due to other circumstances than to the character of 
the nourishment of these infants. 

In this entire controversy one factor deserves emphasis, and perhaps is the 
most important in the etiology of infantile convulsions. Infantile convulsions 
are relatively rare among the better classes and I have never observed true 
manifest tetany and spasmus nutans in children of my private practice. In 
hospital practice, however, eclamptic conditions and spasm of the glottis are of 
daily occurrence, immaterial whether the patient is fed artificially or at the 



VARIETIES OF INFANTILE 'CONVULSIONS 441 

breast. Whenever I have observed laryngospasm and eclampsia in well-nour- 
ished breast-fed children of the well-to-do they were always rachitic and were 
kept for a long time uninterruptedly in close rooms, as is common in prolonged 
cold weather among indulged city children. Therefore, in the better class of 
private patients particularly, hyperirritable conditions appear in nurslings in 
the late winter and spring simultaneously with the development of rachitis of 
the skull. In reviewing all of these experiences I can recognize an exciting 
cause in the alimentary damages which affect the nursling for the individual 
spasmodic attack, but not the basis upon which the pathologic condition of 
general hyperirritability develops. In my opinion the fact is not altered that 
galvanic irritability of the peripheral nerves among infants nourished with 
cow's milk is more decided than with natural food. 

The entire theory of the connection of hyperirritability convulsions of chil- 
dren with nutrition stands upon an insecure foundation. Naturally, it cannot 
be denied that psychically hypersensitive children are attacked by eclamptic 
conditions during acute and chronic digestive disturbances, as, in patients of 
this kind particularly, any derangement of health is calculated to originate 
convulsions. I am firmly convinced that children who, in their earliest youth, 
have suffered from hypersensitiveness, retain a certain tendency to convulsions 
for years, and that these children are liable to spasmodic attacks in any dis- 
ease, immaterial whether it has to do with nutrition. I have observed the facial 
phenomenon in three cases from the age of infancy to beyond the fifth year of 
life in children who were previously eclamptic ; after the third year the laryngo- 
spastic attacks no longer occurred, but a convulsive seizure appeared upon the 
occasion of any febrile disease. 

Therefore, we are of the opinion that rachitis alone, that is, the deleterious 
agencies which give rise to it, is the basis of the hypersensitiveness in question. 
I am fully justified in maintaining that without rachitis there are no hyper- 
irritability convulsions of children. This pertains to the simple forms of this 
convulsive category — spasm of the glottis and eclampsia — as well as to tetany 
and spasmus nutans. Most authors, even those who deny the theory of Kasso- 
witz, must admit that in an overwhelming percentage of cases the children 
affected by spasm are the subjects of rickets. Escherich. whose pupil Loos for- 
merly denied any connection between spasm and rachitis, has characterized 
the spasmodic condition of nurslings dependent upon hypersensitiveness of the 
nervous system as " tetany of the rachitic/' In fact the only question to be 
decided is whether rickets as such causes hyperirritability in these children, 
as Kassowitz believes, or whether the same deleterious agents which give rise 
to rickets are also the cause of general hyperirritability. In any event the 
periodic coincidence of the frequency curve of rickets and of hyperirritability 
convulsions, upon which Kassowitz has laid particular stress, proves an inti- 
mate correlation of these two pathologic conditions. 

In this respect the fact that various authors show different percentages is 
due principally to the lack of uniformity in the valuation of rachitic symptoms. 
Above all, many authors make the mistake of deferring a diagnosis of rickets 



442 CONVULSIONS IN CHILDREN 

until the child shqws a decided rosary and a curvature of the bones of the ex- 
tremities, therefore when the rachitic phenomena are so obvious that we are 
forced to recognize them. It is also a common belief that rickets of the skull 
should only be assumed when marked craniotabes exists. Therefore minor 
grades of rickets or cases of rickets of the skull in process of retrogression are 
overlooked. Naturally it would lead us too far to enter in detail upon the 
symptomatology of the rachitic osseous changes, but it must be remarked that 
soft sutures of the cranial bones and protuberances of the costal cartilages are 
sufficient criteria for a diagnosis of rickets. 1 These are the first changes in the 
rachitic skeleton which can be demonstrated by palpation. If we assume, with 
Kassowitz, that the rachitic bony changes are due principally to the influence 
of atmospheric conditions, such as obtain in foul respiratory air (the so-called 
odor of the poor), and that the same respiratory deleterious factors which give 
rise to rickets are also responsible for nervous hypersensitiveness, the fact is 
explained that in a certain number of cases the first noticeable spasmodic condi- 
tions appear simultaneously with the first palpable signs of rachitis. 

In regard to the relation of craniotabes to spasm of the glottis, the gross 
mechanical explanation of Elsasser that external pressure upon the surface of 
the brain in a yielding skull is a factor in the production of spasm has in my 
opinion been quite improperly rejected, for, as Heubner has lately remarked, in 
exceptional cases such a possibility must be considered. 

The principal connection between craniotabes and hyperirritability convul- 
sions is that craniotabes is an early symptom of rickets of the skull. 

Most opponents of the theory of an association of the so-called idiopathic 
convulsions of young children with, rickets of the skull have claimed that there 
are many cases of craniotabes in which spasmodic conditions are never observed, 
and that, inversely, many rachitics who do not present craniotabes develop 
eclamptic-laryngospastic attacks. Comby asserts that among more than 50 
cases of craniotabes which he collected in the year 1893 only one case of spasm 
of the glottis and two cases of eclampsia were observed. In view of our pre- 
vious explanation these figures of Comby's are not convincing; the only point 
of importance is whether the spasms in question appeared in rachitic subjects 
or in children who were free of the malady. 

In my opinion a certain parallelism exists between the sensitiveness of the 
osseous and nervous systems during their period of energetic growth and devel- 
opment, in the second year of life. As cranial rickets, which is characterized 
by an especially intense growth of the skull, shows a particular tendency to 
develop at this period because, during the active processes of growth, the 
points of opposition of the bony system appear to be unusually sensitive to in- 
juries of a general nature, we may also assume that the brain substance, the 
growth and development of which approximates the development of the skull, 
is likewise vulnerable during the same time. 

Perhaps a closer parallelism exists between the rachitic bony disturbances 

1 See article on " Rickets," this volume. 



VARIETIES OF INFANTILE CONVULSIONS 443 

and the hyperirritability of the nervous system. It might be assumed that the 
same deleterious factors of general nature which incite the rachitic tissue-irri- 
tation in the intensely growing bones at their points of apposition produce a 
change in the developing brain which reveals itself by hypersensitiveness. Ac- 
cordingly the hyperirritability may be regarded as the effect of the rachitic 
damage of the infantile nervous system. 

In the general discussion of these affections the theory of Kassowitz has 
been mentioned, which refers the spasmodic condition and the psychical hyper- 
irritability of rachitic children to a cortical hyperemia due to cranial rickets. 
Escherich believes the respiratory damage which Kassowitz has regarded as 
important in the development of rachitis to be also influential in the etiology 
of the convulsive conditions of children and that the coincident appearance of 
the curve of rickets and of spasm in the late winter and spring is to be referred 
to the prolonged effect of the same noxa, namely, of respiratory influences in 
the insufficiently ventilated and thickly populated quarters of the lower classes 
during the winter. 

Concerning the relation of idiopathic convulsions to rachitis it is imma- 
terial whether Kassowitz's theory of meningeal and cortical hyperemia is ac- 
cepted as the cause of spasm in the rachitic child. As Kassowitz regards the 
rachitic changes of the bones as a hyperemic inflammatory process which is 
particularly prominent in early childhood, especially in the bones of the skull, 
he concluded, on account of the intimate connection of the dura mater with the 
cranial bones, upon a propagation of an inflammatory hyperemia of the latter 
to the meninges and the cortex of the brain. The entire series of symptoms 
of psychical hypersensitiveness of rachitic children — sleeplessness, fright, rest- 
lessness, sweating of the head, shaking spasms, contractures, and particularly 
spasm of the glottis — is the expression of an abnormal irritability of the central 
nervous system dependent upon a cortical hyperemia. Kassowitz based his 
conclusions upon the experimental investigations of Semon, Horsley and 
Krause, who, by faradic irritation, found a center in the cerebral cortex for the 
closure of the glottis, and of Unverricht and Preobraschensky, who discovered a 
cortical center for the expiratory arrest of respiration. 

In opposition to Kassowitz's theory that cortical irritation produces respira- 
tory spasms in rachitics, the assertion has been made that the hyperemic con- 
dition of the cerebral cortex and of the meninges at the convexity, due to 
rickets of the skull, must be general when it exists at all, and that therefore 
the special preference for a hyperirritation of the cortical centers of the res- 
piratory muscles is not clearly understood. In my opinion, however, this rela- 
tion is quite comprehensible. 

If, as has been indicated, a general hyperirritability of the cerebral cortex 
must be assumed as the foundation of all convulsive conditions under con- 
sideration, for the stimulation of an attack, as a rule, certain causative factors 
which quickly irritate the nervous system of the child are essential, such as 
fright, anger, sudden cooling, pain, and the like. I need only call attention to 
the effect of similar irritating factors upon the nervous system of adults. Here 



444 CONVULSIONS IN CHILDREN 

also tonic spasmodic conditions in the muscles of the larynx and of respiration 
play a special role. Loss of speech from fright, hindrance of respiration in ex- 
treme cold, and the like, are evidences that in general hyperirritability the cen- 
ters which preside over the muscles of the glottis and of respiration are much 
more readily excited than any of the others. Accordingly there is no factor in 
the prevalence of respiratory spasms in hyperirritable rachitics which would 
oppose the view of a general cortical hyperirritability produced by hyperemia of 
the surface of the brain. 

If we enter further into the domain of convulsions we will find that in the 
hyperirritability spasms no voluntary muscle of the rachitic nursling is ex- 
empt from spasm. In the eclamptic attacks occasionally not a single voluntary 
muscle remains unaffected. Bcspiratory spasm is present alone only in very 
mild cases, but tonic carpopedal convulsions frequently begin with a crowing, 
spasmodic, inspiratory murmur due to closure of the glottis, and it is quite 
clear that not only the centers for constriction of the glottis and of the res- 
piratory muscles but also the cortical centers of the entire voluntary muscula- 
ture are in such a condition of hyperirritability that the slightest external cause 
may be the signal for a convulsion. If loss of consciousness is included in the 
calculation it is obvious that the entire cerebral cortex is in a hyperirritable\ 
state, which, in our opinion, is the actual foundation for the disturbance in 
function of the nervous system of rachitics here under consideration. 

We have still to consider a view especially propounded by Escherich, ac- 
cording to which the constitutional disturbance designated as status lymphati- 
cus or status thymicus is the ultimate cause of the hypersensitiveness of in- 
fancy, therefore of the group of convulsions under discussion. According to 
Paltauf and Escherich the status lymphaticus is a general disturbance charac- 
terized by a pale and puffy appearance of the skin and by enlargement of the 
entire lymphatic tissue including the thymus, the spleen, the glands of the 
tongue, of the pharynx and of the tonsils. In regard to the thymus it has been 
assumed that through a counteraction of the internal secretions of this gland 
and of the secretions prepared by the thyroid gland an antitoxic effect of the 
organism is produced, and that a disturbance of this function associated with 
enlargement of the organ causes a permanent hyperirritability of the nervous 
system. 

The status thymicus has been held responsible for many sudden deaths in 
infancy, whether justly so is doubtful. Quite as questionable is the relation of 
the status lymphaticus to hyperirritability of the infantile nervous sphere. 
Probably the most serious contradiction of this theory is the occurrence of 
laryngospasm in normal infants in whom no trace of a hyperplasia of the 
lymphatic tissue can be discovered. 

The thymus gland, however, is of importance in the consideration of res- 
piratory spasm in children, as a definite condition of difficult respiration may 
arise from the pressure of the enlarged gland upon the trachea. Stridor con- 
genitus may be the exclusive consequence of hyperplasia of the thymus, as can 
be determined by X-ray examination, and another respiratory anomaly, asthma 



DIAGNOSIS 445 

thy mi cum, consisting of dyspnea and cyanosis with noisy respiration, is the 
most intense form of pressure of the thymus gland upon the trachea. But in 
these processes which run their course with demonstrable enlargement of the 
thymus the hyperirritability convulsions are absent, especially the typical spasm 
of the glottis. 

It has now been definitely decided that the hyperirritability convulsions of 
children bear no relation to the thyroid gland. The investigations of Sand- 
strom, Grley, Vassale, and Generali and Biedl have shown that the tetany 
produced experimentally in animals by extirpation of the thyroid gland is not 
the result of removal of that body but of removal of the parathyroid glands — 
the so-called epithelial bodies; extirpation of the thyroid gland gives rise to 
myxedema, without tetany. 

Furthermore, only a small group of hyperirritability convulsions would 
come under consideration here, namely, the genuine tetany of infancy. At the 
present time, however, the relation of the epithelial bodies to human tetany is 
merely an interesting hypothesis which it is well to know, without deducing far- 
reaching conclusions therefrom. 

In several myxedematous and mongoloid infants I was able for a considera- 
ble time to demonstrate Chvostek's facial phenomenon, and in a myxedematous 
child aged 5 months I found tonic carpopedal spasms of tetanic nature which 
disappeared after treatment with thyroid gland. 



III. DIAGNOSIS 

Further explanation regarding the diagnosis of the individual forms of 
functional spasm in infancy appears superfluous, as sufficient space was devoted 
to it in the clinical description. Only the relation between functional infantile 
spasms and epilepsy, the differential diagnosis between these two varieties of 
convulsion, and the differentiation between infantile spasms of organic and of 
functional nature will be considered. 

First it is necessary to investigate in detail the relation between infantile 
eclampsia and epilepsy, especially as the question arises throughout the entire 
literature of epilepsy whether there be any connection between this neurosis and 
the functional spasms of childhood. 

In the older literature infantile eclampsia, which to-day is included among 
the rryperirritability convulsions, is identified with epilepsy, and Baumes, in 
his monograph of 1805 upon Convulsions of Children, asserted that merely 
an external difference of course and age existed between infantile eclampsia 
and epilepsy. 

In recent times Fere in particular emphasized the identity of the two forms 
of convulsion, and remarked that in his own experience epileptics frequently 
suffered from convulsions in infancy. He found that 34 per cent, of his epi- 
leptic patients had had eclampsia infantum. In the reports of various authors 
the relative percentage of infantile eclampsia and epilepsy differs essentially. 



446 CONVULSIONS IN CHILDREN 

According to Moreau the proportion is 17 per cent. ; Haabermas and Berger 
report 20 per cent. Gowers states that many cases of epilepsy begin in the first 
three years of life, and estimates such an occurrence in about 12 per cent, of 
his patients, which does not include simple infantile eclampsia. According to 
Osier the onset of epilepsy occurs in the first three years in about one-third of 
all cases. 

On the other hand some authors claim to have demonstrated that children 
who suffered from eclamptic attacks in early infancy afterward became epilep- 
tics. Coutts, for example, noted a transition from eclampsia to epilepsy in 
7.5 per cent, of eclamptic children for a long time under his observation. 

Dufour believes that, of 66 eclamptic children, 15, therefore about one- 
fourth, subsequently suffered from true epilepsy. It has also been frequently 
remarked that eclamptic children, even though not epileptic, are afterwards 
nervous and suffer in later life from migraine, chorea, and other functional 
neuroses. 

Henoch and Heubner were able in several instances to follow the gradual 
transition of infantile eclampsia into true epilepsy. 

Among 54 closely studied cases of infantile eclampsia D'Espine found only 
4, therefore 7.4 per cent., of later genuine epilepsy. In these cases the appar- 
ently idiopathic eclampsia passed quite unnoticed into the epileptic condition. 
In one case of D'Espine's in which the convulsions developed in the third year 
and were supposed to be dependent upon phimosis, the attacks disappeared 
transitorily after a circumcision in the fourth year, to recur soon afterward 
with the clinical picture of genuine epileptic convulsions. 

An opposite standpoint is taken by Binswanger, in his recent work upon 
epilepsy, in regard to the connection of that condition with eclampsia infan- 
tum. This author admits a hereditary neuropathic influence which is mani- 
fest in infancy, but believes the fundamental difference between eclampsia in- 
fantum and epilepsy to be that in genuine epilepsy a specific anomaly, known as 
an epileptic alteration of the central nervous system, must be assumed which 
consists in a permanent disturbance of equilibrium between the inhibitive and 
excitomotor centers of the cerebral cortex. On the other hand, Pierre Marie 
believes that the individual is not born an epileptic, but becomes so. It is 
assumed that the greatest number of the infantile convulsions which were noted 
in the histories of 75 to 80 per cent, of his epileptics were due to mild enceph- 
alopathies resulting from infectious diseases, which left cicatrices in the men- 
inges or in the cerebral substance that at a later period were a provocation for 
epilepsy. The latter part of this view, however, cannot receive general recogni- 
tion. Above all, it is opposed by the fact that the attacks of infantile eclampsia 
belonging to the category of hyperirritability convulsions by no means depend 
upon infectious diseases ; on the contrary, after existing for some time they dis- 
appear without leaving any essential disturbance of the cerebral function. 

Further opposed to Pierre Marie's view is the fact that those encephalo- 
pathies in particular which are actually dependent upon acquired inflammatory 
processes of the cerebral cortex in early infancy, for example, Little's disease, 



DIAGNOSIS 447 

are associated in only a small proportion of cases with epileptic convulsions, 
while permanent hypersensitiveness of nurslings which is the foundation of 
genuine eclampsia represents a pure functional disturbance of the central ner- 
vous system without an anatomical foundation. 

In my opinion there is no genetic relation between idiopathic eclampsia of 
infancy and epilepsy of later life. With the great frequency of infantile con- 
vulsions it is not remarkable that a certain proportion of these children are 
subsequently attacked by epilepsy without any connection between the two con- 
ditions being necessary. 

Furthermore, if spasmodic attacks during infancy are admitted in the his- 
tory of epileptics they must be of varying significance. Thus, the occasional 
convulsions of early childhood have absolutely no value in the investigation of 
this question because these early convulsions depend merely upon transitory 
and accidental disturbances of health and do not owe their origin to a general 
functional anomaly of the nervous system. Accordingly, merely the relation of 
hyperirritability convulsions of infancy to epilepsy requires discussion. 

We are to-day in a position to differentiate between hyperirritability con- 
vulsions and epilepsy of early childhood by a consideration of several clinical 
factors. The presence of spasm of the glottis and apnea, the existence of 
mechanical and galvanic hyperirritability in manifest rachitis, should all of 
these factors be simultaneously present, differentiate hyperirritability convul- 
sions of children from epilepsy. In the differential diagnosis, therefore, only 
those cases of infantile convulsions come under consideration which run their 
course without laryngeal spasms. 

As a matter of fact I believe that convulsions which occur in early infancy 
without determinate cause and without the characteristic implication of the 
respiratory muscles which appears in hyperirritability spasms, are to be sepa- 
rated from simple hyperirritability convulsions and regarded as actual infantile 
epilepsy. 

Also we must not build too strongly upon the differentio-diagnostic im- 
portance of rachitic spasmophilia with its symptom-complex, as a combination 
of genuine epilepsy with rachitic hyperirritability is quite tenable. Therefore, 
there will always be a small proportion of cases of infantile eclampsia in which 
the possibility of genuine epilepsy cannot be entirely excluded. 

If epilepsy subsequently occurs in a patient in whom convulsions existed in 
early childhood two conditions are possible: either the infantile convulsions 
were genuine epileptic paroxysms or the individual in question suffered in 
infancy, as is so frequently the case, from occasional or hyperirritability con- 
vulsions which bear no relation to the later epilepsy. 

Of the first possibility it must be noted that the repetition after long inter- 
vals of simple convulsions, with loss of consciousness and without respiratory 
spasms or any other demonstrable acute disease, and continued after the period 
of the infantile spasmophilia, favors the diagnosis of epilepsy. Upon the basis 
of these considerations I have repeatedly made a differential diagnosis between 
epilepsy and eclampsia in early childhood. 



448 CONVULSIONS IN CHILDREN 

Occasionally the period of appearance of the first spasm may furnish sup- 
port for an early diagnosis of genuine epilepsy. Those cases require especial 
study in which the convulsive attacks appear toward the end of the second year 
of life, for then there is always a possibility that we are dealing with the first 
attacks of an actual epileptic affection. 

In the question of the connection of infantile spasm with epilepsy it is 
necessary to consider that severe eclamptic attacks, especially when associated 
with expiratory apnea, may lead to capillary hemorrhages in the central nervous 
organ and in the meninges, and that the residues of such hemorrhages may in 
later life be the starting-point for epileptic disturbances. This may be the 
explanation of the transition of apparently genuine eclampsia of infants into 
true epilepsy, which has been repeatedly reported by trustworthy authors. 

It cannot always be determined positively whether the epileptic attacks of 
early childhood depend upon actual, anatomical, cerebral affections or merely 
upon a functional hypersensitiveness of the centers. To the weak resistance of 
the nervous system in early infancy is due the association of very slight ana- 
tomical lesions with spasmodic conditions, which disappear as the development 
of the nervous system advances, but may recur years later under circumstances 
which cannot be readily ascertained, and particularly at a period when greater 
effort is required in the mental activity of the child. This accounts for the in- 
terval, often of years, between epileptoid infantile eclampsia and later epi- 
lepsy, although the period of quiescence is frequently only an apparent one. 
As a rule, however, such children possess an especially exaggerated nervous 
irritability, with a tendency to severe outbreaks of anger, to hallucinations, and 
to night terrors. 

The literature contains many statements that organic affections of the brain 
may lead to convulsive attacks which show great similarity to functional in- 
fantile spasms. 

In my opinion this can only refer to occasional convulsions. In regard 
to hyperirritability convulsions, apart from nodding spasms there is no possi- 
bility of confusion. 

In support of this statement, in convulsions due to organic conditions laryn- 
gospasm and apnea are almost always absent. Further, in organic cerebral 
affections of children the clonic spasms of the extremities, as a rule, do not 
show the uniform distribution over the entire musculature as in functional in- 
fantile spasms. It may be difficult to decide whether convulsive attacks which 
appear during a febrile disease are to be regarded as occasional febrile convul- 
sions or as due to an organic affection of the brain. For example, a child suffer- 
ing from pneumonia may be attacked by convulsions either of simple, toxic, 
febrile nature or due to a complicating meningitis. There are no general laws 
for the solution of such differentio-diagnostic perplexities. Here the differ- 
entiation of the convulsions must be considered in connection with that of the 
underlying affection. In nurslings with an open frontal fontanelle great ten- 
sion and prominence in that area in the interval free from attacks favors an 
organic intracranial affection. 



PROGNOSIS 449 

The question of organic or functional composition in some cases of spasmus 
nutans associated with nystagmus may cause considerable difficulty, as this 
condition has repeatedly been observed in chronic inflammatory affections of 
the brain or cerebral tumor, and also in epilepsy. As a rule it may be assumed 
that nodding spasms which continue beyond the fourth year of life are asso- 
ciated with organic changes in the brain. The spasmus nutans which appears 
later frequently depends upon hysteria, but then runs its course without nys- 
tagmus. 

If spasms appear in encephalitic cerebral affections or in tumor of the 
brain, focal symptoms are usually present in the free intervals which exclude a 
purely functional nature of the spasm. Here also laryngospasm is exceedingly 
rare except in the case of a combination of rachitic spasmophilia with an 
organic cerebral affection. 

IV. PROGNOSIS 

In the occasional spasms the prognosis as regards recovery depends alto- 
gether upon the severity and the gravity of the underlying affection. The 
spasmodic attack alone only exceptionally leads to a fatal issue and in my 
experience has occurred only in one affection, whooping-cough. Here, however, 
as already mentioned, we must always reckon upon the possibility of an effusion 
of blood into the brain, which may arise in combination with spasms during 
severe attacks of pertussis. Nor can it be said that the onset of convulsions 
during infectious diseases indicates a particularly serious course, since children 
with very mild febrile disturbances are seized with convulsions, and after the 
affection has run its course are restored to complete health. 

With the second group of occasional spasms, which we have learned to recog- 
nize as myotonia of infants, the condition is somewhat different. Here the 
permanent spasms of the muscles of the extremity are usually of unfavorable 
prognostic import as regards the course of the underlying affection, since they 
indicate a severe toxic condition of the organism. To this statement an ex- 
ception is made in hereditary syphilis, in which myotonic spasms are observed 
even in mild cases, which are relieved, simultaneously with the underlying affec- 
tion, by antisyphilitic treatment. 

The prognosis of hyperirritability spasms depends upon three circum- 
stances : 

1. The importance of the individual spasm ; 

2. The effect of the same upon the general hyperirritability of the nervous 
sphere ; 

3. The connection of the latter with the neuroses of later childhood. 
Concerning the first point attention has already been directed to the gravity 

of the various hyperirritability convulsions, especially the respiratory spasms 
with the type of expiratory apnea. Here, in contrast to the occasional convul- 
sions, the spasm itself is the ominous factor, whereas the underlying disease, 
rachitis, is by no means associated with danger to life. 
30 



450 CONVULSIONS IN CHILDREN 

In regard to the prognostic importance of the individual spasmodic condi- 
tions the rule may serve that those cases are to be regarded as favorable in 
which only inspiratory laryngeal spasms occur, while children in whom the ex- 
piratory arrest or cessation of respiration appears often are always in a certain 
degree of danger. 

As regards the importance of hyperirritability convulsions of children in 
general the prognosis is chiefly dependent upon the involvement of the respira- 
tory muscles during the seizures, and as the convulsions are more intense in the 
early life of the child than after the second year, the danger in the first two 
years is correspondingly greater. Also those forms of spasm in which loss of 
consciousness plays an essential part are of more unfavorable prognostic import 
than those in which the irritation is principally of subcortical nature. Accord- 
ingly the genuine tetany and nodding spasms of children warrant a favorable 
prognosis. 

In the introduction to this article it was explained that the convulsive chil- 
dren of the first years of life very commonly are the nervous and hysterical 
subjects of later childhood. It appears that the hypersensitiveness of the in- 
fantile nervous system which arises early is not altogether proportionate with 
the arrest of the convulsions dependent upon it and with the disappearance of 
the mechanical and galvanic hyperirritability which may be present. 

Although, as has been stated, I cannot assume a definite connection between 
epilepsy and hyperirritability spasms from my own experience, nevertheless, in 
the greater proportion of such children a certain neuropathic predisposition 
may be positively demonstrated. As the result of a long family practice I must 
emphasize the fact that some children who have suffered from eclamptic at- 
tacks and respiratory spasms during the first years of life have retained their 
tendency to convulsions until the age of puberty, although after the fourth year 
the respiratory spasms were replaced by convulsions arising in various dis- 
turbances of health, therefore by occasional spasms. 



V. TREATMENT 

We have attempted to show that the convulsions of children are always the 
sequels of some other pathologic condition. Therefore, in many respects their 
treatment must coincide with the management of the underlying affection. 
In a prophylactic respect the prevention of infectious diseases, intoxications 
and injuries, on the one hand, and of rickets, on the other, is the best prophy- 
laxis for the convulsive conditions of infancy. 

First, a few general directions for the treatment of the spasm itself. 

A child attacked by clonic convulsions, with loss of consciousness, must first 
be freed of its clothing and the respiration maintained by every means at our 
disposal. 

If there is a suspicion of poisoning or evidence of an over-filling of the 
stomach, vomiting should be induced and eventually lavage of the stomach 



TREATMENT % 451 

should be practised. If the intestines are overloaded enemata should be given 
to empty the bowel. 

Hydrotherapy is of special value in these attacks associated with loss of 
consciousness. During the convulsions, immaterial what their origin, the 
unconscious child should be placed in a lukewarm bath. While in the bath 
ablutions of cold water should be applied to the head and nape of the neck, or 
the head may be enveloped in cloths wrung from ice-water and changed at 
brief intervals. Small particles of ice may also be applied to the head and neck 
during the bath. 

Chloroform inhalations are especially efficacious, and should be given in all 
prolonged convulsive states no matter what the age of the patient. The best 
method is to employ pure chloroform by the drop method. 

Whether compression of the carotids is suitable in the treatment of con- 
vulsions of infancy I am not in a position to decide. At this time positive indi- 
cations for this method of treatment are lacking, as the distribution of blood 
in the brain during the eclamptic attacks has not yet been determined. Ac- 
cordingly there is no definite basis for judging the effect of this measure, which 
is of some value in the epileptic and uremic convulsions of later life. Vene- 
section must be considered from a similar view-point. On the other hand, in 
long-continued attacks of spasm the application of cutaneous irritants is very 
serviceable in the form of mustard applied to the lower extremities, or of pro- 
longed fresh mustard baths. 

The remedial measures thus far mentioned are to be employed in persistent 
spasmodic attacks. The transitory eclamptic laryngospastic conditions which 
occur in rachitic children require energetic and rapid interference, for although 
the attack is of brief duration the child is in great danger in consequence of 
arrested respiration. Here the strongest cutaneous irritants must be applied 
at once. The child should be completely enveloped in cold cloths, or cold water 
should be applied with some force, by means of a syringe, to the sternum, the 
region of the heart, and along the vertebral column, to stimulate deep inspira- 
tions. The tongue must also be drawn forward and artificial respiration 
practised. If a battery is at hand faradization of the thorax should be em- 
ployed. 

During such attacks nothing is to be expected of drugs, not even of chloro- 
form, which cannot be inhaled on account of the apnea. 

In the consideration of special therapy for the convulsions of children the 
treatment of occasional spasms must be distinct from that of hyperirritability 
convulsions. 

The treatment of occasional spasms must always be purely symptomatic. 
It is necessary to quiet the irritated nervous system by means of narcotics and 
to remove the underlying affection which gives rise to the convulsion. If the 
condition is the effect of foreign bodies, surgical measures are necessary; if 
due to a febrile disease the hyperthermia must be combated. 

In regard to the convulsions of fever a cooling treatment by means of hy- 
drotherapy prevents as well as aborts the attack in every febrile infectious dis- 



452 CONVULSIONS IN CHILDREN 

case. For children who react readily with convulsions during febrile affec- 
tions Raudnitz has proposed a prophylactic treatment for several months with 
small doses of the bromids, and states that he has seen good results from their 
use. 

There are no specifics to abort the occasional spasms when once they have 
appeared. The treatment of spasms originating from the intestine coincides 
with the hygiene, the nutrition, and the therapy of infantile intestinal diseases. 
Eapid emptying of the bowel is necessary, and is best accomplished by suitable 
doses of calomel. 

During the attacks of clonic spasm enemata of chloral (% gramme per 
dose), together with the internal administration of the bromids (1 gramme to 
50 of water, a tablespoonful every hour), are particularly serviceable. 

For prolonged convulsions tincture of musk may be employed (1 gramme 
to 50 of syrup, a teaspoonful every hour). The favorable effect of inhalations 
of chloroform in prolonged convulsions has already been remarked. 

Eegarding myotonia of the new-born and young nurslings a direct treat- 
ment is impossible. In the permanent spasms originating from the intestine 
a proper diet must be instituted; if the condition depends upon severe septic 
and cutaneous affections, these must be treated; if it results from syphilis, 
mercury must be administered. The form of myotonia dependent upon syphilis 
is particularly amenable to proper therapy. 

The permanent spasms, dependent upon chronic autointoxication associated 
with atrophy, are most rapidly relieved by the infusion of normal salt solution, 
the simultaneous administration of small doses of calomel, and proper food. 
(See Figs. 11 and 12.) 

In regard to the hyperirritability convulsions of children my remarks will 
be brief. Their treatment entirely coincides with the therapy of the under- 
lying condition, rickets. Treatment by phosphorus, instituted by Kassowitz, 
is exceedingly effectual in such convulsions, as well as in the other nervous 
phenomena of early childhood dependent upon rickets, all of which yield readily 
to the influence of the drug. Most rapid to disappear is spasm of the glottis. 
Here phosphorus frequently has an actually miraculous effect; children who 
have suffered from spasm of the glottis several times daily for weeks are en- 
tirely relieved of this life-threatening laryngeal neurosis. The relief of the 
eclamptic attacks requires a longer time, and most protracted is the cure of 
tetany. It must, however, be emphasized distinctly that the disappearance of 
the spasmodic condition, which often occurs within a few weeks, must not in- 
terrupt the administration of phosphorus for the underlying affection, rickets, 
as the convulsions may very readily begin anew when this treatment is dis- 
continued. Phosphorus should therefore be administered at least for several 
months. In severe eclamptic conditions there can be no objection to the ad- 
ministration of phosphorus at first in combination with the bromids, 5 or 6 
teaspoonfuls of a 2 per cent, solution of sodium bromid being given daily 
during the first week in addition to a teaspoonful of a mixture of oil of phos- 
phorus. 



SUPPLEMENT: PATHOLOGIC ANATOMY 453 

Phosphorus is most serviceable in the form of phosphorus cod-liver oil or 
phosphorus lipanin, or in an emulsion of oil as proposed by Kassowitz : 

Phosphori 0.01 

Olei jecor. Aselli 100.0 

M. ct Sig. One teaspoonful daily. 

V- 

Phosphori 0.01 

Lipanini 100.0 

Saccharin 0.1 

Solve in pauxillo Ale. absol., 

01. citri gutt ...Ill 

Administered as above. 

3- 

Phosphori 0.01 

Olei amygdalar. dulc 30.0 

Sacch. albi, 

Pulv. Gummi arabici, aa 15.0 

Aq. dest 40.0 

Administered as above. 

As all possible derangements of health, especially nutritive disturbances and 
diseases of the intestine, serve as exciting factors for attacks of spasm in 
hypersensitive children, a proper nutritive therapy is of the greatest import- 
ance, and as Finkelstein and Thiemich have demonstrated a direct dependence 
of electric contractility upon the manner of nourishment, much latitude is 
allowed this point in a therapeutic respect. Furthermore, as the etiology of 
hyperirritability convulsions is in intimate relation with rickets, although the 
latter affection is primarily dependent upon respiratory damage, fresh air, 
residence in airy rooms, ventilation of the nursery, and the avoidance of un- 
pleasant odors are essential. Lastly, the prophylaxis of hyperirritability con- 
vulsions coincides with the general hygiene of infancy. 



VI. SUPPLEMENT: PATHOLOGIC ANATOMY 

To refer to anatomical lesions in a functional neurosis is really a contra- 
diciio in adjectis. In construing the anatomical anomalies in the central ner- 
vous system which have been found in children who suffered from convulsions 
we must always remember that most of these children did not succumb to the 
convulsions but to some other simultaneous affection, so that in the individual 
case the first question to decide is whether the changes found in the nervous 
system can be brought into association with the simultaneous disease or the one 



454 CONVULSIONS IN CHILDREN 

which lias caused the spasm. This warning is especially accessary when an at- 
tempt is made to classify tetany as an organic disease of the central nervous 
system upon the basis of anatomical findings. Here a further complicating 
factor arises, the want of uniformity in the conception of tetany on the part of 
various authors who have reported anatomical findings in infantile tetany. 
Some anatomical lesions which have been found in children who succumbed to 
permanent spasms certainly have nothing in common with tetany ; on the con- 
trary, they belong to the realm of myotonia of nurslings, which I have sepa- 
rated from the category of tetany. 

Again, where severe affections of a different nature (infectious diseases, 
chronic renal processes) were present, the findings do not permit of the con- 
clusion that the changes found in the central nervous system bear any possible 
connection with the intravital spasmodic disease. In any event a definite ana- 
tomical basis can be construed neither for the occasional nor for the hyperirri- 
tability spasms of infants. 

The lesions found in the central nervous system in children who suffered 
from spasm will be viewed differently if we take into consideration whether or 
not the attacks were of severe laryngospastic and apneic nature, and especially 
whether death occurred during an eclamptic-laryngospastic paroxysm. There 
can be no doubt that, as capillary hemorrhages occasionally occur in the cere- 
bral cortex and in the meninges during attacks of pertussis, so also, in conse- 
quence of severe laryngospastic attacks, may hemorrhages appear in the central 
nervous system, which, however, are then not the cause but the consequence of 
the spasmodic condition. 

The first anatomical findings in tetany were reported by Bonome and Cer- 
vesato. 

In two children, aged one year and twenty-one months respectively, who had 
succumbed from febrile affections and were reported to have suffered from 
tetany, these authors found anomalies in the cervical enlargement and in the 
dorsal portion of the spinal cord. In the gray substance there was atrophy of 
the ganglion cells, increase of the neuroglia cells, here and there a diminution 
of the newly-formed neuroglia with the formation of irregular cavities. The 
lumbar cord and the peripheral nerves were exempt from change. These 
authors regarded the anatomical process as a poliomyelitis with predominant 
involvement of the ganglion cells of the anterior horns and a permeation of the 
process into the more deeply situated portions of the white substance. 

Since we know that tetany, as such, does not give rise to a febrile disease, 
a severe infection in both cases is exceedingly likely, in the course of which a 
secondary poliomyelitis had arisen. It is also possible that these were in fact 
two rapidly fatal cases of acute poliomyelitis in children previously suffering 
from tetany. Both cases occurred in close succession in the Children's Clinic 
in Padua, and as the cumulative appearance of poliomyelitis in definite regions 
is a condition frequently observed, the lesions of the spinal cord demonstrated 
by Bonome and Cervesato may very properly be referred to epidemic polio- 
myelitis without any connection whatsoever with tetany. 



SUPPLEMENT: PATHOLOGIC ANATOMY 455 

The black pigmentation within the roots of the motor spinal and the cere- 
bral nerves, stained by Marchi's method, which Zappert and, after him, Thie- 
mich, E. Miiller and Manicatide have found in nurslings who had succumbed 
to a severe disease with spasms, has also been demonstrated in cases of tetany 
(Kirchgasser), but we now know that it is of no relevant importance in the 
solution of convulsions. In a case of infantile tetany E. Peters found a hemor- 
rhagic pachymeningitis in the cervical and lumbar enlargements which was 
limited to the anterior and lateral portions of the periphery of the spinal 
cord, and continued to the coverings of the anterior roots as well as to the in- 
terstitial and connective tissues in the vertebral canal. In another instance 
he was able to demonstrate a neuritis of the motor roots, in a third case in- 
flammatory changes within several spinal ganglia. All of these children, how- 
ever, suffered from other severe disease (pneumonia) to which they succumbed. 

Filia has examined the central nervous system of five children who suffered 
from hyperirritability convulsions, of whom one succumbed to pneumonia fol- 
lowing scarlatina, two died of extensive atrophy, and two of laryngospasm. In 
one of the last two cases there were congenital changes in the spinal cord: a 
double central canal existed and the anterior of these canals was so distended 
as to suggest hydromyelia. In the cerebral cortex a deficiency in radial and 
tangential fibers was conspicuous. There w r ere also microscopic findings in the 
cerebral cortex, in Poland's zone, especially thrombosis, foci of softening, and 
changes of the ganglion cells. The macroscopic investigation of the central 
nervous system revealed no pathologic change. 

Carl Beck recently described two anatomical findings in children suffering 
from tetany. One, a child six years of age, who had suffered from visceral 
syphilis and contracted kidney in addition to typical tetany, showed, by means 
of Marchi's method, degenerative changes of the ganglion cells of the cerebrum, 
particularly of the motor cortical region, which could be recognized by an accu- 
mulation of fatty granular cells and granular globules, and further a fatty de- 
generation of the medullary fibers in the posterior roots of the spinal cord. 
The same changes were found in a boy agec* one year, of whom it was only 
stated that he suffered from tetania gastrica. In both of these cases investi- 
gated by Beck the anterior roots were intact. 

The lesions thus far reported in no wise justify the theory advocated by E. 
Peters that infantile tetany is an affection always dependent upon an organic 
disease of the spinal cord. 



DISEASES OF THE NOSE AND PHARYNX PECUL- 
IAR TO INFANCY (EXCLUDING TONSILLITIS) 

By J. ZAPPERT, Vienna 



DISEASES OF THE NOSE 

The cases of acute disease of the upper air passages which come under 
the observation of all practising physicians readily show that these affections 
occur in children much more commonly than in adults. Therefore, since coryza 
and pharyngitis are by no means rare in adults, the conclusion must be drawn 
that — aside from the great anxiety of parents for their children — these mala- 
dies are more severe in infancy than in later years and that in childhood 
certain affections are more frequent and often obtain a serious aspect. Chronic 
diseases of the nose and pharynx, which are more common in adults, are usually 
observed by the specialist rather than by the family physician, but in children's 
practice there are quite a number of cases which require a diagnosis by a gen- 
eral practitioner before they are recommended to the specialist. 

The diseases which, either by their course or nature, are peculiar to infancy 
will be the subject of our present discussion, and so far as possible our atten- 
tion will be devoted to them exclusively. We shall disregard, or merely men- 
tion in passing, those pathologic conditions of the nose and pharynx of which 
the symptomatology is alike in children and in adults and which are more 
peculiar to later youth. The laryngological and rhinological methods of inves- 
tigation and their findings will not be comprehensively discussed, and are only 
mentioned in so far as they are indispensable for explanation. This omission 
is not intended as a disparagement of these noteworthy methods, but it is my 
experience that they are very difficult to employ in children's practice, and the 
younger the patient the more impracticable do they become, so that the physi- 
cian is compelled to make a diagnosis without the aid of such measures. 

Accordingly, the affections which will be considered in this article are lim- 
ited to acute rhinitis, involvement of the nose in infectious diseases, especially 
in syphilis, to epistaxis, foreign bodies in the nose, acute inflammations of the 
nasopharynx including Pfeiffer's glandular fever, to lymphadenitis retropha- 
ryngealis, retropharyngeal abscess, and adenoid vegetations in the nasopharynx. 
Incidental remarks will also be made concerning other portions of infantile 
rhinology. 

456 



ACUTE RHINITIS (CORYZA) 457 

ACUTE RHINITIS (CORYZA) 

Children are no less exposed to simple acute inflammation of the nasal mu- 
cous membrane, coryza, than adults. The accompanying symptoms, however, 
vary according to the age of the child. 

Etiology. — Among the causal factors colds and contagion are mentioned 
most frequently. We cannot discuss the question, in how far the influence of 
temperature is responsible for the development of a coryza, but we are not justi- 
fied in ignoring this generally accepted view in our practical work. It is quite 
positive, however, that infection plays a much greater role in the development 
of coryza and is a particularly decisive factor in nurslings. In the case of 
children attacked by coryza who have not been out of doors for days or weeks 
previously, an inquiry concerning the health of the other inmates of the house- 
hold, or an examination of them, will usually discover some member of the 
family or a servant who has been similarly attacked, and thus disclose the 
origin of the affection in the child. To know this and to express it forcibly is 
not superfluous from a practical standpoint. The anxious care of many 
mothers to prevent colds in their children will be effectually combated thereby, 
although not, perhaps, without the fatalistic assurance that protection of the 
child against catarrhal infection is almost impossible. Finally, the physician 
himself may be the occasional source of contagion in a child if he has carried 
on his children's practice during the period of his own rhinitis, often pro- 
longed through several winter months. 

Other causes which occasionally give rise to coryza in adults, such as the 
occupation inhalation of finely pulverized or toxic substances and drug intoxi- 
cation, are of minor importance in children. 

On the other hand, it is a well-known fact that influenza very often attacks 
quite young children, even nurslings, the initial symptom being a severe co^za. 
Although the rhinitis of influenza will be considered later somewhat in detail, 
it is necessary at this point to express a warning word in regard to attaching 
too much importance to influenza as a cause of coryza in children. Since the 
severe epidemic of influenza which passed over Europe in 1889-90 physicians 
are inclined to regard every acute febrile affection, associated with severe irri- 
tative phenomena and slight lesions of the respiratory apparatus, as influenza, 
and in the last few years it has been a quite regular occurrence, at the outbreak 
of a febrile coryza in children, to state that " influenza has again appeared." 
At variance with such a custom is the fact that any coryza may produce tem- 
peratures of 40° C. (104° F.) in children, to which Kohts called attention in 
1878, therefore at a time when influenza as a pandemic was still unknown in 
Central Europe. 

As yet we are unfamiliar with the bacteriologic agent of coryza. Chiari 
mentions as exciting factors the asthmathos ciliaris, diplococcus coryzge, pneu- 
mococcus, streptococcus, staphylococcus pyogenes albus, aureus, cereus, flavus, 
etc. All of these microorganisms, however, have their habitat in the normal 
nose, therefore their pathogenic importance is limited. 



458 DISEASES OF THE NOSE 

Rhinitis is a disease of the cold season, occurring in young and old, and is 
never absent from December to April in families with many children. iUso 
during the late spring and summer — especially after a drought — there is often 
a conspicuous accumulation of cases of rhinitis in children which is probably 
to be referred to a pathogenic agent which flourishes in heat and is readily 
transmitted by dust. A cause analogous to that of hay fever must also be taken 
into consideration. 

Symptoms. — In the clinical picture of acute coryza, in young children par- 
ticularly, the hyperemia may frequently be sharply differentiated from the 
secretory stage. 

In such cases, in a previously healthy child, the disease begins with fever, 
rapidly rising to 40° C. (104° F.), associated with extreme lassitude. The 
patient is very restless or sleepless, and may even be somewhat somnolent. 
Older children complain of headache and thirst. This last symptom often occa- 
sions the remark from the mother that notwithstanding the fever the child is 
" quite hungry," and forthwith overfeeds it with milk, as is shown by dys- 
peptic discharges. In older children it is easy to distinguish between a desire 
for much water and an aversion for all kinds of food. In uncomplicated coryza 
vomiting and convulsions are rare. In this stage of the disease objective exami- 
nation reveals but little. The nasal mucous membrane is of a darker color and 
swollen, the posterior pharyngeal wall, exclusive of the tonsils and the palatine 
arches, is also hyperemic ; otoscopic examination shows at most an injection of 
the tympanic membrane, without inflammatory phenomena. 

These slight local symptoms may readily be the forerunners of all possible 
diseases of infanc}^, but the diagnosis becomes certain if, after a duration of 
one or several days of these initial symptoms, the second stage, that of nasal 
secretion, appears and the constitutional symptoms rapidly decline. There is 
frequent sneezing, at first with a serous, later a mucoid or mucopurulent secre- 
tion, sometimes noisy respiration, red, glistening skin of the nose especially in 
older children, and fissures and excoriations on the alae of the nose, due to the 
flowing secretion which has not been carefully removed. In uncomplicated 
cases all of the disagreeable constitutional symptoms soon disappear; only the 
nasal secretion, which is at first profuse, remains and it also disappears grad- 
ually in the course of eight to fourteen days. 

The catarrhal process is not always so simple, and in nurslings especially 
very unpleasant complications may arise. 

In the child the impermeability of the nose is of great importance. Even 
in children beyond the age of nursing this symptom causes inconvenience, as 
they are often unable to blow the nose on account of the occlusion and cannot 
describe the seat and nature of the difficulty. From this inconvenience in the 
night an actual disturbance arises. Accustomed to nasal respiration, they do 
not readily learn to breathe through the mouth ; therefore they sleep poorly and 
are awakened if the mouth should be closed for a time. The awakening often 
occurs with the symptoms of night terrors. The consequences of nasal occlusion 
in coryza may therefore resemble those of adenoid vegetations. Even more 



ACUTE RHINITIS (CORYZA) 459 

annoying is the dryness and scratching in the throat, which, particularly after 
sleep, may interfere in swallowing and speech and cause tormenting cough. 
The dryness produced by mouth breathing, combined with the flow of mucus 
upon the posterior pharyngeal wall, produces a catarrhal irritation of the 
pharynx. Under some circumstances in nurslings this impermeability of the 
nose may become serious. Henoch describes, in a characteristic manner, the 
dyspnea due to nasal stenosis, which may lead to alarming attacks of asphyxia. 
For this sudden hindrance of respiration Bouchut offers the explanation that in 
consequence of enforced mouth breathing the tongue is drawn backward, the 
tip touching the hard palate, thus covering the entrance to the larynx. 1 In a 
desperate case the tip of the tongue must be held with a catgut suture and 
drawn forward. This acute asphyxia occurs more commonly during nursing — 
a time when an infant with nasal obstruction is forced to breathe strongly 
through the mouth. But even without such sudden attacks impermeability of 
the nose causes a decided hindrance to the ingestion of food. Upon closing 
the mouth the child becomes dyspneic, therefore the nipple of the breast or of 
the bottle is soon relinquished and often, after a brief combat between hunger 
and the fear of nursing, food is refused. It is clear that both of these factors, 
difficulty in respiration and in ingestion of food, may seriously affect the 
health, and that the prognosis of coryza is therefore more grave in infants 
than in older children. If fever and insomnia are also present, and if these 
symptoms last for a few days, the condition — aside from the possibility of sud- 
den death due to nasal asphyxia — may actually become life-threatening. Death 
due to infantile rhinitis has been reported by West, Simon, v. Hiittenbrenner, 
and Baginsky. Kussmaul was able to save a child who was troubled by 
asphyxia during nursing by feeding for a week with the stomach tube. 

Other accompanying symptoms and sequels of acute rhinitis are subordinate 
to those already mentioned. Thus the impaired sense of smell which is often 
so disturbing to adults is merely recognizable to older children, although the 
taste as well as the appetite of the child may also be unfavorably influenced. 

Excoriations at the nasal orifices and upon the upper lip are much less 
common in infants than in children past the first year of life. Their absence 
in the former is probably due to the blowing of the nose, which prevents con- 
tact of the corroding secretion; and the spontaneous off-flow of the nasal mucus 
in infants, in consequence of their recumbent posture, occurs posteriorly rather 
than anteriorly. " Running nose " and excoriations are most frequently en- 
countered in children who have learned to walk but who have not yet acquired 
the habit of cleansing the nose. There is a tendency of such catarrhal excoria- 
tions to become covered with yellow crust and thus assume the character of an 
impetiginous eczema. 

*The doubling up of the tongue, particularly when complicated by a long loose 
frenulum, may even lead to a " swallowing of the tongue," of which I have seen an in- 
stance. The tip of the tongue is drawn backwards and leads to instant suffocation. 
One of the famous German clinicians who died a few years ago told me twenty years 
ago of a baby of his own who died of the same accident. — Editor. 



460 DISEASES OF THE NOSE 

Among other sequels of infantile coryza its I runs mission to the larynx and 
bronchi is of serious import. In by far the majority of cases this propagation 
of the coryza is limited to the pharynx and larynx and is then for the most part 
characterized by a change in the timbre of the cough. The careful observer 
will sometimes note the transition from the toneless, scant cough with occluded 
nose to the tormenting, prolonged, staccato, pharyngeal cough which occurs 
principally in the morning, and to the rough barking tone of the laryngeal 
catarrh. The further extension of the catarrh into the bronchi and the lungs 
is by no means rare and depends often upon an influenzal character of the 
affection. Individual peculiarities undoubtedly play a prominent role. In 
some children coryza always remains localized in the nose; I know an anxious 
mother who proudly states that owing to her precautionary measures her child 
"never coughs when it has a cold." Much more common, however, are the 
cases of rhinitis which are almost regularly followed by implication of the 
larynx, sometimes associated with pseudo-croup. In such conditions we often 
learn that the father or the mother showed a similar tendency in their youth 
to a distribution of coryza, which would lead us to assume, as the cause for 
these sequels of the affection, hereditary anatomical anomalies of the nasal 
structure, and particularly adenoid vegetations, which recur in several gener- 
ations. 

The distribution of a coryza to the accessory cavities of the nose, on the one 
hand, and to the ear, on the other, must be variously considered. In a child, 
particularly an infant, the accessory nasal cavities are but slightly developed ; 
the consequence of this anatomical peculiarity is an infrequency of disease of 
these regions in early infancy. 

We know from the investigations of Kunkel (1873) that in the new-born 
the pharyngeal opening of the Eustachian tube is somewhat below the floor of 
the nasal cavity so that it is more readily surrounded by a descending secre- 
tion. On the other hand, it possesses but a slightly thickened margin, so that 
the opening has a more radiating form and is not funnel-shaped as in later life 
(Kohts). Therefore there is a plentiful opportunity for a transmission of the 
nasal catarrh to the ear, and as a matter of fact catarrh of the tubes and otitis 
media are among the most common accompanying conditions of infantile and 
especially of nursling coryza. It is the duty of every physician to bear this 
contingency in mind ; he will then not be surprised, if there is a sudden rise of 
temperature in the course of coryza, and increasing restlessness and insomnia, 
that the case has already progressed beyond the first stage of coryza, and will 
think of a possible flow from the ear when epithelial masses in the auditory 
passage or a negative otoscopic investigation precludes a knowledge of the con- 
dition of the tympanic membrane. Even when there is no well-defined condi- 
tion of the ear older children who are affected by coryza complain of " ear- 
ache," probably due to a slight catarrh of the Eustachian tube. Not rarely 
the primary symptoms of coryza are overlooked by the parents or neglected. 
The restlessness and symptoms of pain are referred to colic and the physician 
is not called until discharge from the ear appears. There are, however, epidem- 



ACUTE RHINITIS (CORYZA) 461 

ics of nasal catarrh, with a special tendency to ear effection, in which the ini- 
tial nasal symptoms are so slightly developed as to give the impression of a pri- 
mary otitis. Rey describes epidemics of this apparently primary middle ear 
catarrh, and I also have observed that at certain periods nearly all the children 
in my practice who were affected by coryza showed aural affection, while at 
other times very much severer forms of rhinitis ran their course without 
implication of the ear. 

In a review of the factors which characterize coryza of children, and espe- 
cially of nurslings, in contrast with that of adults, we note the following : The 
abrupt onset with marked febrile phenomena, the slower transition into the' 
stage of secretion, the important consequences of nasal occlusion as regards 
sleep and the ingestion of food, the possibility of asphyxia, the rare but dan- 
gerous conditions of exhaustion, the frequency of pseudocroup and the great 
tendency to affection of the ear. 

It scarcely requires mention that, in addition to those children who present 
a great proportion of these conditions when attacked by coryza, there is a pre- 
dominant majority of little patients to whom all of the symptoms are absent, 
the coryza running just as harmless a course as in adults. 

The transition of simple coryza into the chronic catarrh is not common in 
children in the absence of other predisposing factors. Such factors are fur- 
nished especially by adenoid vegetations, scrofula and syphilis. We are then 
not dealing with simple rhinitis but with the sequel of other diseases which 
will be considered under their proper headings. It is only necessary to mention 
that coryza which frequently relapses should always awaken a suspicion of 
adenoid vegetations, and in this sense often requires treatment. 

Thus far we have considered simple acute coryza — rhinitis par excellence — 
which, in most cases at least, must be regarded as a substantive infectious dis- 
ease whose pathogenic agent is still unknown and the particular localization of 
which is in the nose. The nasal mucous membrane, however, is also involved 
in the majority of acute infectious diseases, either as a first point of attack or 
secondarily. 

I. It has been indicated in this article that even in infancy influenza may 
primarily attack the nose and produce severe symptoms. The diagnosis be- 
tween simple coryza and that due to influenza is not always easy and is often de- 
pendent solely upon secondary symptoms and sequels. If there is a case of 
influenza in the family a febrile coryza in a child at once arouses suspicion, 
particularly as infants — inversely to other infectious diseases — are exceedingly 
susceptible to influenza. As a rule the fever and constitutional symptoms are 
severer in influenza than in ordinary coryza. and convulsions at the onset are 
not rare. The nasal secretion, especially in older children, soon becomes puru- 
lent and is often very profuse. The demonstration of Pfeiffer's influenza bacil- 
lus in the nasal mucus is not very difficult and naturally is the only positive 
proof of a correct diagnosis. In favor of influenza is the rapid propagation of 
the disease to the deeper respiratory passages and the development of severe 
otitis with a hemorrhagico-purulent exudate, as well as the occasional forma- 



462 DISEASES OF THE NOSE 

tion of vesicles upon the discolored, dark red, tympanic membrane. An un- 
common but very serious complication of influenza is disease of the meninges, 
which occurs as a secondary infection. Disease of the auxiliary cavities in 
children in general is rare, as has already been mentioned, but its occurrence in 
later childhood must be considered. Neuralgia, muscular pains, and general 
lassitude cannot be demonstrated in nurslings but these conditions occur in 
older children just as in adults. From these facts, therefore, it is evident that 
the coryza of influenza is a common and by no means insignificant affection in 
children and also in infants. 

II. It has been remarked that the cumulative attacks of coryza in older 
children in the early, hot summer days, present a condition analogous to hay 
fever. Contrary to this hypothetical conception, however, is the fact that in 
unquestionable epidemics of hay fever children are just as frequently attacked 
as adults and develop the same symptoms of the affection (Phobus-Blackley). 

III. In measles the nasal mucous membrane is always affected early, and 
after a maculate redness, soon shows diffuse hyperemia and swelling. The 
nasal symptoms are not very severe; sneezing and secretion are usually only 
present in the stage of onset. Sometimes a swelling of the mucosa and a ten- 
dency to chronic coryza remain. That the pathogenic agent, so long searched 
for without result, is present in the nasal secretion of measles is made exceed- 
ingly likely by Mayr's old inoculation experiments. The frequency with which 
disease of the ear and of the deeper respiratory passages occurs in measles is 
well known. 

IV. Rotheln (rubella) usually runs its course with slight involvement of 
the mucous membrane. The implication of the nasal mucosa is correspondingly 
slight, although according to Pospischill it is never entirely absent. 

V. In erythema infectiosum, which has lately been much discussed, the ab- 
sence of initial rhinitis has frequently been emphasized. Judging from my 
experience this view, as well as "that of an exemption of the pharyngeal mucous 
membrane, which is often maintained, must in time be corrected, the latter 
condition not being characteristic of the affection. 

VI. Coryza does not belong to the initial symptoms of scarlatina; in con- 
trast to the foregoing affections disease of the nose is secondary. On the other 
hand, purulent coryza appears as an accompaniment of necrotic processes in the 
throat. This was regarded by Eilliet and Barthez as a serious sign and it de- 
serves this appellation in full measure, although not so much on account of 
the local affection as because of the severe pharyngeal disease of which it is us- 
ually an associate. The condition runs its course with decided swelling of the 
nasal mucosa and considerable muco-purulent secretion, causing an extension 
of the inflammation of the mucous membrane to the nasopharyngeal space and 
pharynx and a decided hindrance of nasal respiration. In debilitated, feverish, 
septic children the disturbance of sleep and the deficient inhalation of oxygen 
resulting from this condition are by no means of slight importance. The dysp- 
neic attacks of " pharyngeal stenosis," due to occlusion of the nose and pharynx, 
which resemble laryngeal croup, are well known, but a differentiation is possi- 



ACUTE RHINITIS (CORYZA) 463 

ble through the absence of laryngeal cough and the predominant involvement 
of the nasopharynx. In such cases cleansing of the nose by means of pledgets 
of cotton, and — as affection of the ear is already present in this stage of scar- 
latina, or is very likely — irrigation of the nose with antiseptic fluids, are of 
vital importance and often bring about decided amelioration. For this pur- 
pose LeLorier introduces a soft urethral catheter with lateral openings into the 
nose, leaving the free end outside the mouth. To avoid corrosion by the secre- 
tion around the nasal orifices the frequent application of lanolin, borated vase- 
lin, zinc ointment, etc., is advisable. 

VII. In diphtheria disease of the nose plays an important role. In infants 
especially that organ may be the primary and perhaps the only seat of the 
diphtheritic infection, or is secondarily involved in a distributed pharyngeal 
process. Primary nasal diphtheria in children, even in those but a few days 
old, is markedly infectious and is justly feared in foundling asylums. Usually 
the onset of the affection is insidious, beginning with the flow of fluid mucus ; 
often in this stage only the unilateral appearance, in contrast to ordinary 
coryza, is suspicious (Hiittenbrenner). The secretion gradually assumes a 
hemorrhagico-purulent character, the nasal openings become excoriated and not 
infrequently are covered with diphtheritic ulcers; the deep cervical glands en- 
large, the temperature shows a decided elevation, the child appears to be 
severely ill, becomes somnolent, and occasionally, but not invariably, particles 
of membrane are found adherent to the walls of the nose or to the cotton pled- 
gets, which clears the diagnosis. Sometimes there is a propagation to the 
pharynx and larynx. As a rule death soon releases the sufferer. Nasal diph- 
theria in nurslings therefore represents a conspicuous septic form of the 
malady. 

Less dangerous, but nevertheless serious, is nasal diphtheria as a secondary 
phenomenon of disease of the larynx. This form also is at first characterized 
by a mucoid secretion which soon changes to a purulent or hemorrhagic compo- 
sition. Excoriations, ulcerations, edematous swellings form at the nasal ori- 
fices just as in the variety last described. As a rule, enlargement of the lymph 
glands is associated with this transmission of the diphtheritic process to the 
nose, but this is not alone due to an inflammation of the nasal mucous mem- 
brane but is an expression of the septic character of the diphtheria, and diph- 
theria of the nose may be regarded as its signum. 1 Although these are the 

1 The observation that " glandular swelling is not alone due to the nasal mucous 
membrane, but may be the expression of a septic character of diphtheria " may per- 
mit of some modification. The worst cases of septic diphtheria are those of mixed 
origin. The enormous glandular swellings are less due to the diphtheric bacillus or 
toxin, than to copious infection. Indeed, uncomplicated diphtheria exhibits no big 
glandular swellings, and then only when it is nasal. The worst cases of septic diph- 
theria, when not of a mixed character, are frequently not attended with much swell- 
ing. They result from a direct absorption from the (eroded and bleeding) bacillus 
and toxin into the blood circulation, circumventing the lymph apparatus altogether. 
In those terrible cases death can be averted only by very frequent mildly antiseptic 
irrigations of the nares and by large doses of diluted alcohol and other stimulants and 
antiseptics internally. — Editor. 



464 DISEASES OF THE NOSE 

signs of a severe course of the disease the prognosis is not so unfavorable as in 
the foregoing variety. 

A form of nasal disease designated rhinitis fibrinosa or rhinitis pseu- 
domembranacea has been much discussed among pediatrists. This affection 
is characterized by a pathologic picture developing with quite harmless symp- 
toms of occlusion of the nose and dryness of the pharynx, which may continue 
for weeks or even months, when suddenly — often to the great surprise of the 
physician — a membranous coating appears in the nose. A case reported by 
Henoch, occurring in a daughter of Traube's, is celebrated and characteristic. 
This girl, aged eight years, was attacked with coryza, moderate fever, decided 
snoring while asleep, and complained of a hindrance in respiration near the 
root of the nose. The pharynx and epiglottis revealed catarrhal redness. After 
a duration of several days the child expelled a tough white membrane of about 
the length of a finger from the nose, followed later by a smaller one of similar 
composition. A few days afterward the child was well. A longer duration, 
with a more gradual discharge of particles of croupous membrane is the rule. 
There is always absence of membrane in the pharynx as well as of severe gen- 
eral symptoms. The disease is scarcely infectious, although it occasionally ap- 
pears in several children of the same family. Is this rhinitis fibrinosa, or pseu- 
domembranacea as it has been called, true diphtheria ? The condition was for a 
long time obscure. At first only cocci were found, principally pneumococci 
(Abel) ; the bacillus of diphtheria was not demonstrated (v. Stark). In later 
investigations, however, the diphtheritic organism was found with such regu- 
larity (Baginsky, Concetti, Stamm, Abbot, Luigi, Scheinmann, Treitel and 
Ivoppel, Buys, Morf, Neumann, and others) as to leave no doubt of the true 
nature of the affection. Post-diphtheritic paralyses also have been reported 
after rhinitis fibrinosa (Luigi). From these reports it may be concluded with 
certainty that this form of inflammation of the nasal mucosa is simply an 
attenuation of a diphtheritic disease and that Spirig is right in rejecting the 
name rhinitis fibrinosa and substituting for it the term rhinitis diphtheritica. 
Naturally, in all cases of this kind the employment of serum is necessary in 
the treatment. 

VIII. In varicella eruptions appear upon the nasal mucous membrane, es- 
pecially where it is in contact with the external skin, as well as on the pharynx 
and conjunctivae. 

IX. Gonorrheal rhinitis, although rare, must be regarded as an assured 
condition. The original opinion that the gonococcus cannot thrive upon the 
nasal mucous membrane has been proved fallacious by the investigations of 
Finger, Grhon, and Schlagenhaufer. Primary gonorrheal disease of the nose 
in the new-born is to be placed in the same category as gonorrheal conjuncti- 
vitis and, like that affection, is due to contamination by the infectious vaginal 
secretion of the mother (Weber, Fraenkel, Stoerk, Ziem, Bresgen, etc.). Ac- 
cording to Stoerk it has been maintained by Leopold Muller that a secondary 
infection of the nose from the diseased conjunctivae is possible and is even fre- 
quent ; he has invariably found gonococci in the nasal mucus of infants affected 



ACUTE RHINITIS (CORYZA) 465 

with blennorrhoea neonatorum. Although this finding is not synonymous with 
nasal gonorrhea, nevertheless, in children with such affections of the eye, the 
nose must be carefully watched and upon the appearance of a secretion of pus 
antiseptic or astringent solutions must be employed. 

Treatment. — From the discussion of the symptomatology of infantile 
coryza it is evident that the treatment covers all of the gradations from 
purely expectant to urgent, life-saving measures. 1 

In older children in whom the coryza runs its course without special dis- 
turbance treatment is not necessary, but we must bear in mind the possibility 
of complications. If the initial phenomena are severe an attempt may be made 
to abort the attack, i. e., to bring about secretion in the first stage, that of fever 
and h} T peremia. The child is put to bed, and a diaphoretic tea is given (lime 
blossoms, elder flowers, hot lemonade), perhaps with the addition of a few 
decigrams of sodium salicylate. Filatow, who does not regard sodium salic3 T - 
late very highly, advises in "endemic grippe," which he differentiates from 
" epidemic grippe " or influenza, muriate or sulphate of quinin, either in the 
form of powder, 0.06 for each year of life, or in solution. Instead of quinin 
analogous preparations, such as aristochin, euchinin, or, when fever and head- 
ache are prominent, antipyrin or salipyrin. An old method of treatment of 
coryza consists of hot foot baths; of less use in children's practice are sina- 
pisms to the back, employed by the older physicians. As a rule, in small chil- 
dren and especially in nurslings, all of these measures should be dispensed with 
in the febrile stage of onset, the treatment consisting merely of cold compresses 
to the head, " bathing with vinegar/' and cold packs. 

Whether older children with well-developed coryza are to be treated is a 
matter of preference of the physician or of the parents. The number of reme- 
dies is much too large and great reliance should not be placed upon any one of 
them. The local measures consist of inhalants, the insufflation of powders, 
applications, spraying or mechanical cleansing of the nose. 

1 The large number of recommendations proves the difficulty of treatment. The 
nares and post nasal space must be left clean. The mildest application is salt water 
7: 1000. Cotton pledgets soaked in it should be used frequently. Warm irrigations 
should be made frequently, hourly or in longer intervals, from a small Whitall Tatum, 
Birmingham, Dessar or other cup, care being taken that the current reaches the throat. 
Adrenalin (1:1000) could be applied by means of the pledget. Cocain is not so good 
because the secondary hyperemia is great. Astringent solutions (zinc, sulph., zinc, 
sulpho-carbol., alum) should be quite mild. In occasional cases the difficulties are 
great. I have been compelled to use the actual cautery on the luxuriant mucous mem- 
brane for days in succession, and to keep the mouth open constantly to keep the baby 
from suffocating. We had no adrenalin then which might have rendered the electro- 
cautery unnecessary. 

The difficulties of ozena are by no means overdrawn. Irrigations should be made 
at least twice a day; a few days with "saline solutions" to accustom the patients 
to the procedure; then with permanganate of potassium 1: 3000-4000. Once every few 
weeks I use a saturated solution of silver nitrate. Before applying it the lips and 
orifice of the nose must be moistened with a fairly strong salt solution. The applica- 
tion should be made with cotton wrapped round a straight whalebone or silver probe 
long enough to reach from the nares to the pharynx. A spoonful of salt solution should 
be swallowed immediately for obvious reasons. — Editor. 
31 



466 DISEASES OF THE NOSE 

Preparations of menthol are preferable for inhalation, and lately have been 
combined with formaldehyd in the form of for man cotton. Also serviceable 
are camphor, oil of turpentine, ammonia (Hager-Brand remedy: acid, carbol., 
liq. amnion, caust., aa 5.0, spirit. 15.0, aq. dest. 10.0; Sig. Inhalations every 
two or three hours from the bottle or a few drops poured on thick blotting- 
paper and held to the nose [Kiesselbach] ). In children's practice, however, 
these and many other inhalants are unsuitable, for unless they are breathed 
very carefully with closed mouth they readily produce cough and burning sen- 
sations in the eyes and frighten the child by their pungent odor. Under such 
circumstances a repetition of the inhalation often meets with great resistance. 
Furthermore, the success of these inhalants is problematic, and if their result 
is limited to sneezing it may be attained in some other manner. 

Insufflation of pulverized substances by means of an insufflator may be prac- 
tised with children provided they remain quiet. Here, in addition to the as- 
tringent-antiseptic effect, sneezing and expulsion of the stagnant nasal secre- 
tion are of no trifling importance. Among the remedies employed for this 
purpose are sodium sozoiodol, boracic acid, tannic acid, and alum. The various 
powders which contain morphia or opium should not be employed in children. 

In infants our purpose will best be attained by applications to the mucous 
membrane of the nose, which requires but slight skill with a small brush or 
with a wooden applicator covered with cotton. Such a cleansing of the nose is 
necessary in nurslings because of the difficulty in the ingestion of food. For 
this purpose watery or glycerized solutions of boracic acid (2 per cent,), silver 
nitrate (% per cent.), protargol (3 — 5 per cent.), sulphate of zinc (0.5 per 
cent.), alum (10 per cent.), or cocaine (2 per cent.) will prove of service, or 
if crusts have formed, salves are preferable, either yellow precipitate, boracic 
acid or zinc ointment, vaselin with menthol, olive oil, etc. Even when the in- 
tranasal application of salves is not employed, moistening of the nasal orifices 
with these ointments, glycerin, or cold cream, is desirable. 

In all of these local measures more importance is to be attached to a 
thorough cleansing of the nose than to an antiseptic action of the remedies. 
Kiesselbach's process — the introduction of cotton pledgets with a bent forceps 
or with a spiral tampon carrier, which is turned further by the hand and left in 
place for fifteen minutes — should be considered in the coryza of nurslings. 

Finally, washing of the nose, for which a number of implements are in use. 
The employment of all instruments presupposes a willingness on the part of 
the patient, with which we cannot reckon in infant practice, as crying and ir- 
regular respiration not only make the value of these nasal washings very il- 
lusory but may also cause injury to the ear. This form of treatment for coryza 
has therefore been somewhat neglected in children. 

In the local treatment of the nose we must not overlook the sequels of coryza, 
which are often more important than the primary disease. Particular attention 
must be given to the difficulty in sucking. The nose should be cleansed several 
times daily,- perhaps before each feeding, with a plug of cotton. If the breast 
or the bottle is not well taken the food must be given with a spoon. In cases 



SCROFULA OF THE NOSE 467 

of this kind breast-fed children must be nourished with milk pumped from the 
breast. If sufficient food is not taken at one time it must be administered 
more frequently. Stubborn cases of rejection of food render necessary feeding 
by means of the stomach-tube. Some authors advise cocainization of the nasal 
mucous membrane, even in nurslings, when food is rejected in consequence of 
coryza; for example, Nageli-Ackerblom introduce a drop of a solution con- 
taining cocain 2.0, aq. dest. and glycerin aa 50.0 into each nasal opening three 
or four times a day by means of a dropper. 

An affection which differs from ordinary rhinitis and requires a separate 
description is 

SCROFULA OF THE NOSE 1 

Scrofula is the collective term for all chronic processes which appear in 
small children upon the mucous membrane of the upper respiratory passages, in 
the glands, and in the skin. The nosologic conception of this term is now more 
uncertain than ever and the identification of scrofula and tuberculosis is still 
general among pediatrists (Henoch, Biedert, Monti, Soltmann). This condi- 
tion of affairs would account for Spitzmiiller's recent definition of scrofula: 
By scrofula we understand that change in metabolism, and particularly in the 
circulation of the lymph, whereby a pathologic predisposition arises in the 
organism to infect itself with pyogenic bacteria and the tubercle bacillus. 
With this indefinite classification of scrofula it is clear that the affection of the 
nose also can only be defined with difficulty, and whether he shall diagnosticate 
a simple chronic inflammation or scrofula in the individual case very often 
devolves upon the personal view of the physician. 

In recent text-books upon rhinology (Chiari, Bresgen, and others) scrofula 
of the nose is not considered as a substantive affection but is included with the 
various forms of chronic rhinitis. 

If we intend clinically to adhere to scrofula of the nose, the condition may 
be regarded as such when there are no recognizable external causes for the ex- 
isting pathologic picture (adenoid vegetations, foreign bodies), and it must 
therefore be assumed that the changes present are t^ie expression of a consti- 
tutional disease. 

Pathology. — Nasal scrofula is a part phenomenon of the " torpid " form 
of the affection, to which it gives the characteristic impress. The condition is 
one of hypertrophic rhinitis in which the nasal mucous membrane is swollen 
and reddened, the lower turbinated bone usually enlarged ; not rarely there is 
loss of epithelium, and ulceration of the nasal mucous membrane. A constant 
and disagreeable symptom is the accumulation of a profuse mucopurulent 
secretion within the nose, leading to occlusion, as well as to eczema, fissures, 
excoriations and ulcers at the outlet of the nasal passages. 

These lesions upon the external skin are very tenacious. Exceedingly often 
they are the cause of inflammation and stasis of lymph in the skin of the 

1 See article on "Scrofula," this volume. 



468 DISEASES OF THE NOSE 

nasal alse and of the upper lip, which are then characteristically swollen and 
reddened. After this chronic-purulent stage of rhinitis has lasted some time 
there appears almost always a swelling of the lymph glands under the sterno- 
cleidomastoid and along the deep jugular vein, which become very large and 
even suppurate. Occlusion of the nose leads to alteration in speech, which 
assumes a characteristic "nasal twang" (Baginsky), and to attacks of sneez- 
ing and coughing. Chronic catarrh of the pharynx and larynx is a frequent 
result of rhinitis. Purulent affections of the middle ear as well as lachryma- 
tion and catarrh of the conjunctiva, due to occlusion of the tear ducts, are not 
infrequent. 

Quite a different picture is presented by atrophic rhinitis, ozena. Here the 
mucous membrane is in a stage of involution, the turbinated bones are small 
and atrophic, and in consequence the nose is wide, the secretions scant and 
formed into crusts, and, above all, the odor from the nose is unbearable. A 
scientific controversy exists as to whether ozena belongs to hereditary syphilis 
and scrofula or only to the first-named affection. Without attempting to prej- 
udice a decision we shall refer ozena to syphilitic disease of the nose. 

Prognosis. — Naturally the prognosis of scrofulous rhinitis cannot be sepa- 
rated from that of the underlying affection. It is not particularly unfavorable, 
although we must not forget that in a moderate number of cases swelling of the 
bronchial glands and other signs of tuberculosis may appear in addition to 
scrofula. The nasal symptoms, however, are prone to improve, and when we 
note the vast number of children between three and fourteen years of age with 
scrofulous rhinitis, and the small number of adults with this nasal affection, 
we must admit that the trouble very often disappears. Ozena is of unfavorable 
import and almost incurable. 

Treatment. — The treatment consists primarily in combating the scrofu- 
lous constitution, and the internal administration of iron and cod-liver oil. 
Iodin and sea baths, mountain climate and favorable nutritive conditions are 
of particular value (see Soltmann's article on Scrofula and Tuberculosis, this 
volume). Locally, medicated bougies, insufflations of powder, applications and 
sprays are to be employed. 

Following Catti, Chiari advises nasal bougies consisting of small gelatin 
cones of tannin (0.1), copper sulphate (0.02), silver nitrate (0.1), potassium 
iodid (0.1), etc. Solutions of silver nitrate (2-10 per cent.), tannin, glycerin 
and iodin, creolin vasogen (2 per cent.) (Striibing), eucalyptol (ol. eucal. fol. 
1.5, spir. vini 20.0 and aqua 200.0, Baginsky), etc., are serviceable for appli- 
cation. 

For a spray or for nasal washings normal salt solution, potassium perman- 
ganate, boric acid, etc., may be employed. Particular attention should be de- 
voted to careful cleansing of the external nose, removal of crusts, application of 
ointments, and eventually the cauterization of ulcers or of the moist eczema. 
A process that is worthy of mention is that of Witthauer, who after loosening 
the crusts in the nose, cauterizes with a 2 per cent, silver nitrate solution or 
with a solution of iron chloride, and every evening introduces cotton tampons 



HEREDITARY SYPHILIS OF THE NOSE 469 

dipped in glycerin and water and thickly covered with powdered alum (Ba- 
ginsky). In severe cases we must resort to surgical treatment of the hyper- 
trophied turbinated bones. 



HEREDITARY SYPHILIS OF THE NOSE 

The nose is a point of predilection for hereditary lues; in fact no other 
part of the organism shows such early and permanent signs of the malady. For 
clinical purposes it is best to divide the affection into an early and a late form, 
but that these are not so sharply separated as might appear will become evi- 
dent later. 

Symptoms. — The characteristic early form of lues is coryza syphilitica. 
This prevails in an overwhelming majority of infants who are hereditarily 
syphilitic and in those cases in which symptoms appear in the first months of 
life it is probably never absent. It is frequently a forerunner of the luetic ex- 
anthem and is sometimes the only sign of infantile syphilis. Coryza syphilitica 
is often congenital (among 63 cases investigated for such evidence by Hoch- 
singer it was found 38 times), or becomes manifest in from four to six weeks. 
The syphilitic coryza of nurslings in its characteristic form is a rhinitis hyper- 
plastica. The mucous membrane is greatly swollen and injected, and the 
secretion, at least at the onset, is quite scant. As the swelling principally in- 
volves the lower turbinated bones the interior of the nose is greatly narrowed. 
In general in recent cases the diffuse inflammatory process is limited to the 
anterior portions of the nose. 

The narrowness of the internal nares is the primary cause of the clinical 
symptoms. 

A very characteristic factor of syphilis of the nose is the snuffling during 
breathing and is usually the first symptom which brings the child to the phy- 
sician. 

Even in this stage, the nasal opening is often found excoriated with fissures ; 
fever is never present in uncomplicated syphilitic coryza. 

In cases that are rapidly and energetically treated syphilitic coryza may be 
arrested in this stage and, for a time at least, give rise to no further trouble. 

More commonly the condition occurs in connection with the secretory stage. 
The secretion is never very profuse but causes corrosion of the skin and a puru- 
lent or even hemorrhagico-purulent discharge. The respiration now assumes a 
more sluggish character, and sometimes, although not commonly, sneezing 
occurs. 

From limitation of the nasal respiration dyspnea arises as well as difficulty 
in the ingestion of food. The first-named symptom is rarely so marked as in 
acute rhinitis. The latter, however, may lead to decided disturbance, analogous 
to that described under acute coryza. 

The excoriations upon the outer surface of the nose are quite conspicuous; 
there may be crustaceous ulcers at the nasal orifices and upon the upper lip 



470 DISEASES OF THE NOSE 

which, by occluding the nares, naturally increases the difficulty of nasal respira- 
tion. 

In severe untreated cases, in addition to syphilitic coryza an ulcerative 
necrotic stage may occur which may lead to deformity of the nose. We shall 
recur to this condition later. 

Hereditary nasal syphilis may also be the cause of disturbances in the imme- 
diate vicinity of the nose, but it never gives rise to bronchitis and pneumonia, 
and in this respect it differs from coryza simplex of the new-born. 

The prognosis of the early form of nasal syphilis is accordingly not unim- 
portant. Aside from the immediate disturbance in consequence of hindered 
nourishment, the condition may result in further changes in the nose which will 
be discussed as late symptoms of hereditary lues. 

Even with the early institution of antisyphilitic treatment the course is 
chronic and insidious. Failure to recognize the condition and negligence in 
treatment may readily lead to far-reaching local disturbances. 

The treatment coincides with that of general syphilis and needs no special 
explanation. Local treatment of the nose is usually unnecessary. If it appears 
desirable inunction or painting with a y 2 -l per cent, solution of corrosive sub- 
limate is of service. 1 

Syphilis does not confine itself to this early stage ; there may be changes in 
the nose which do not appear until the close of infancy or even later and which 
must be regarded as an expression of syphilis hereditaria tarda. We owe a 
minute knowledge of these late forms of nasal syphilis to Fournier, and Gerber 
has contributed an interesting report of this condition. In adhering to Four- 
nier's classification and terminology we shall not enter into a discussion of his 
conception of syphilis hereditaria tarda as a late manifestation of a previously 
unrecognized or recognized hereditary syphilis, which may perhaps require 
complement. It is a fact that as a rule the late forms of hereditary nasal 
syphilis appear unexpectedly toward the end of infancy and even later, without 
obvious precursors of such a condition. 

Ozena. — A form of nasal affection which is sometimes encountered in the 
subjects of hereditary syphilis is ozena (rhinitis chronica atrophicans or atro- 
phica, Chiari). Among rhinologists this affection has been much studied and 
greatly discussed. The etiology especially has been the subject of comprehen- 
sive researches, and in addition to a number of bacterial findings in ozena the 
relation of the disease to syphilis and scrofula has frequently been investigated. 
Thus Stoerk, an authority of unquestioned importance, is of the opinion that 
all cases of ozena are the late results of syphilis. 

To decide or investigate this point is not the function of the pediatrist. So 
far as we are concerned it is certain that ozena often develops in individuals 
hereditarily syphilitic, whether or not this constitutional disease is the only 
basis of the affection. Their connection has been proven, or at least considered 
very likely by a great number of investigators (Stoerk, Gerber, Hochsinger, 

1 The application of corrosive sublimate | to 200 seems too strong. — Editor. 



HEREDITARY SYPHILIS OF THE NOSE 471 

Fournier, etc.). Syphilitic ozena is predominantly an affection of late child- 
hood and puberty or, more correctly, it usually becomes manifest at this stage 
of life. Unfortunately, the onset is very insidious, characterized neither by 
pain nor other obvious symptoms, and the affection usually presents itself to the 
physician in full development. 

The anatomical lesion of ozena consists in an atrophy of the mucous mem- 
brane, of the cartilages, and of the turbinated bones, so that the interior nares 
appear dilated. The secretion is not profuse, and is comprised less of mucus 
than of pus and serous fluid ; it is very tenacious, adhering firmly to the walls 
of the nose, where it forms crusts and decomposes. From this decomposition, 
perhaps under the influence of specific microorganisms, a dreadful odor ema- 
nates which, although less noticeable to the patient himself than to those about 
him, makes the affection exceedingly mortifying. In children this affliction 
may result in an actual inhibition of normal development, as it renders contact 
with other persons impossible and prevents attendance at school or the learning 
of an occupation. Such persons are greatly restricted in their opportunities 
for maintenance and are much to be pitied. Ozena is perhaps the most cruel 
legacy which a syphilitic father can leave to his child. In some cases it is 
possible, by rinsing the nose, to uncover decomposed ulcers or even portions of 
sequestrated bone ; sometimes the patients are able to remove small particles of 
bones from the nose by blowing. This, according to Chiari, is a noteworthy 
differentio-diagnostic factor of syphilis in contrast to ordinary ozena, in 
which bone necrosis does not occur. 

Sometimes, after the removal of these particles of bone and antisyphilitic 
and antiseptic treatment, it is possible to cure ozena. In the majority of cases, 
however, the prognosis is very unfavorable and Stoerk's pessimistic view of the 
affection is only too correct. 

Convincing as is the theory of this author of a relationship between heredi- 
tary syphilis and ozena, the therapeutic test of this view is of little consequence : 
the antiluetic treatment is absolutely ineffectual — a result, however, which is 
also frequently noted in the late forms of syphilis. The local treatment of 
syphilitic ozena likewise offers but slight hope of success. The internal ad- 
ministration of iodin, antiseptic washings, insufflation of powder, inunctions, 
vibration massage, curettement, electrolytic cauterization, as well as injections 
of paraffin, lately practised, for the formation of a lower turbinated bone and 
extension of the surface of the mucous membrane (Fliess), have been attempted 
with varying results. 

In addition to ozena, marked changes in the shape of the nose occur as the 
consequence of hereditary syphilis. The fact that these deformities, which are 
without question associated with syphilis, are often combined with ozena — 
in Gerber's experience, in 43.3 per cent, of his cases of ozena — should also serve 
to substantiate the syphilitic nature of the latter. 

The nasal deformities which are recognized by Fournier and Hochsinger are 
as follows : 

A common change of the nose results in simple pug-nose; the dorsum of 



472 DISEASES OF THE NOSE 

the nose is somewhat depressed and the root broadened, so that the nostrils are 
forced forward and upward. 

A second important deformity results from complete destruction of the ex- 
ternal structure of the nose, whereby " the tip of the nose, after loss of the 
cutaneous covering, adheres to the upper lip" (Hochsinger's Bocknase). 

A very characteristic and well known form of hereditary syphilis is the 
saddle-nose : Here the depression of the dorsum is so marked that in profile it 
sinks deeply under the frontal bone, the tip of the nose being drawn upward 
as though torsion had been made upon the bridge. This nasal deformity is 
quite common; to the expert it is the unmistakable sign of syphilitic taint in 
the youthful bearer. 

Less common are two other deformities of the nose, the knowledge of which 
we owe to Fournier. 

One is a lateral depression designated the spectacle nose (Pincenez or Knei- 
fernase), in which the forepart of the nose is somewhat broad and on both sides 
of the dorsum it appears depressed, corresponding to a nose upon which eye- 
glasses have long been worn. 

The second deformity is the so-called lorgnette nose, which is probably 
better designated the telescope nose. The anterior soft part of the nose is 
forced into the posterior bony portion, like the parts of an open telescope. This 
produces a fold of skin over the forepart of the nose at the point where it sinks 
into the posterior portion. If the tip of the nose is pulled forward and down- 
ward the deformity disappears and the organ assumes its normal contour. 

How do these manifold deformities of the nose in hereditarily syphilitic 
individuals originate ? Fot some of the cases which are found in lues heredi- 
taria tarda there is no satisfactory history. As Fournier has remarked, they 
have no prior pathologic history but have developed gradually or have existed so 
long that the patient has forgotten their onset. In other cases necrotic proc- 
esses are present in the bone, mostly affecting the vomer, the lower turbinated 
bone and the ethmoid bone (Fournier). According to Gerber such a necrosis 
may occur in the hyperplastic stage of nasal syphilis in small children and early 
produce the nasal changes which are regarded as a late form of syphilis. But 
destruction of the internal nares may appear even in nurslings, although, as 
emphasized by Hochsinger, they then involve only the cartilaginous and cuta- 
neous portions of the nasal structure. 

Hochsinger furnishes some very important material for the study of this 
condition. Among 256 infants with hereditary syphilis he found changes in 
the nasal structure in 62, nearly all of which conformed to the deformities 
mentioned above ; also in a few cases there was perforation of the nasal septum, 
and a child aged seven months showed perforation of the hard palate. This 
destruction was always associated with a purulent or hemorrhagico-purulent 
discharge from the nose; therefore Hochsinger designates this form of nasal 
syphilis as a stage of exulceration, that is, a deformity associated with the 
simple hyperplastic or suppurative stage of coryza syphilitica. 

If all of these findings are borne in mind those cases of nasal deformity 



FOREIGN BODIES IN THE NOSE 473 

which are met with as the expression of lues hereditaria tarda, without a plausi- 
ble prior history, lose to some extent their strangeness. We can probably 
assume that these are the permanent results of an early syphilitic nasal affec- 
tion which was treated insufficiently or perhaps not at all. A sharp distinction 
between early and late symptoms of nasal affection in hereditary syphilis, as 
has been frequently made, then disappears and it need not be surprising that a 
constitutional disease which shows a predilection for the nose in intrauterine 
life as well as in early infancy eventually leaves in this structure unmistakable 
and permanent consequences. 



FOREIGN BODIES IN THE NOSE 

The presence of foreign bodies in the nose occurs in children much more 
commonly than in adults. This is explained by the tendency of children to 
introduce small, smooth objects into the nose in play, which remain there 
readily on account of the narrowness of the orifices and the insufficient power of 
expulsion. It is also rare for the child to designate the cause of his nasal 
trouble, so that the physician must of himself determine the presence of a 
foreign body. Eeasons for such a suspicion are offered by unilateral occlusion 
of the nose, sneezing, altered voice, headache, painfulness and swelling of the 
nose. If the foreign body has been present in the nose for some days there is 
usually a purulent, sometimes 'bilateral, nasal catarrh which gradually assumes 
a fetid character, leading to corrosion of the skin at the entrance of the nose ; in 
this stage confusion with nasal diphtheria is possible. The catarrhal inflamma- 
tion of the nasal mucous membrane may be propagated posteriorly, affecting 
the Eustachian tube and with this the ear. Under some circumstances foreign 
bodies may remain in the nose for months or even years without being 
recognized. 

The foreign substance is sometimes discovered immediately upon inspection 
of the nose or after it has been cleansed. In other cases this is more difficult, 
especially where there has been time for reactive phenomena. Touching of the 
nasal mucosa with a solution of cocain and adrenalin is a valuable aid as it 
causes constriction and anemia of the membrane. 

The foreign bodies that are encountered in children are various; beads, 
stones, buttons, beans, peas, cherry-seeds, and pellets of cotton are the most 
common. The most unpleasant substances are those which swell in the nose, 
such as beans and peas ; Boyer observed a case in which a pea introduced into a 
nostril had begun to sprout. In small children, particularly in infants, vomited 
masses are sometimes discharged through the nose; such an occurrence may 
also happen in diphtheritic paralysis during deglutition. As a rule such masses 
pass quickly through the nose, but a retention of firm particles is possible. 
They may then decompose and lead to irritation of the nasal mucous membrane. 
A special form of foreign substance in the nose is represented by animal para- 
sites. Aside from the cases in which caterpillars, flies, earwigs, ascarides, 



474 DISEASES OF THE NOSE 

oxyuris, etc., gain entrance to the nose it is necessary to consider the severe in- 
flammatory phenomena which arise in that structure and in the auxiliary cavi- 
ties from the larvae of flies. In temperate climates these occurrences are very 
rare, and then are often only secondary infections in somnolent children with 
decided nasal secretion; in tropical regions, however, there is a disease due to 
the larvae of flies (myiasis, Peiper 1 ), associated with severe symptoms, which 
leads to destruction of the internal nose and, by giving rise to meningitic phe- 
nomena, may even terminate fatally. 

At this point the relation of the boring of the nose to intestinal parasites 
must be briefly considered. The laity see a reliable symptom therein and 
bring their children to the physician for this phenomenon alone for medicine 
to expel the worms. Naturally, we must reject such an idea and negative a 
connection of worms with nasal boring. Perhaps this as well as so many other 
popular views and superstitions may have arisen from a misunderstanding of 
some former medical experience, as that the transmission of the ova of the 
oxyuris by means of the finger into the nasal passage causes itching, which is 
plausible. 

Treatment. — The treatment of foreign bodies in the nose consists in their 
removal. In mild cases strong blowing of the nose during occlusion of the free 
side will prove effectual ; in other cases nasal washing, which, however, must be 
avoided if objects which are liable to swell are suspected. If these measures are 
insufficient to expel the substance an instrument must be used — a Daviel spoon 
introduced behind the obstacle to force it forward. More hazardous is the 
manipulation with a forceps, by which means however round flat substances 
are readily forced backward. This should be avoided, because the foreign body 
may become attached in the nasopharyngeal space or find its way into the 
larynx and trachea. In older children painting with a cocain-adrenalin solu- 
tion prior to the operative interference is advisable. Ulcers due to pressure re- 
quire antiseptic treatment, which is best accomplished by the insufflation of 
powder (sodium sozoiodol, dermatol, . boric acid, etc.). If the foreign body is 
so embedded that it cannot be removed per vias naturales, operative interference 
by division of the nose must be considered. 

Injections of chloroform-water (Chiari), alum, carbolic acid, alcohol, and 
turpentine, insufflations of tobacco smoke and fumes of ether for the removal of 
animal parasites have been practised with success. 



BLEEDING FROM THE NOSE (EPISTAXIS) 

Epistaxis in infants is rare. This may be due to absence of causative con- 
stitutional conditions, to the fact that the mucous membrane of the nose is less 
succulent and rich in blood, or to the lesser liability to excoriations from pick- 



1 See volume on " Diseases of Metabolism of the Blood and Animal Parasites and 
Toxicology " p. 573, et seq. 



BLEEDING FROM THE NOSE (EPISTAXIS) 475 

ing and scratching of the nose. It must not be overlooked that in the nursling 
in the recumbent posture bleeding from the back of the nose, as well as from 
the nasopharynx, is more apt to occur posteriorly than anteriorly, so that even 
if epistaxis is present it need not be apparent. These considerations are of 
practical importance, for Swoboda has found that in children with melena 
neonatorum the passage of blood through the intestine is due to hemorrhage 
from the nose. In his cases there was also epistaxis, but Hochsinger reports a 
case in which bleeding of the nose ante partum led to the discharge of 
hemorrhagic masses from the intestine, and not until an inspection of the 
pharynx was suggested by Swoboda's publication was epistaxis discovered; 
after tamponage of the nose the hemorrhage was arrested. These cases of 
nose-bleeding in the new-born, however, are rare. More common is a bloody 
admixture of the nasal secretion in chronic diseases of the nose, as in coryza 
syphilitica. 

Epistaxis in older children, as in adults, is due to trauma, constitutional 
conditions, or local changes in the nose (" spontaneous " epistaxis). 

Strictly speaking, most forms of epistaxis must be considered as traumatic, 
since it is usually some external cause which leads to injury of a nasal blood- 
vessel and to hemorrhage. Here, however, we will consider as traumatic epis- 
taxis only those forms which are due exclusively to external agency. This 
usually consists of a blow or fall upon the nose. In severe accidents it is also 
necessary to consider fracture at the base of the skull. Aside from possible 
deeper injuries of the nasal structure these traumatic hemorrhages as a rule 
neither diagnostically nor therapeutically give rise to great difficulty; more 
disagreeable are the external injuries to the nose. 

Few of the constitutional conditions, which in adults often lead to nasal 
hemorrhage, are common to childhood. Even in valvular disease of the heart, 
nephritis, and pulmonary affections, in which stasis occurs, epistaxis is rare 
in infancy. The condition is most frequently seen in acute endocarditis, of 
which diagnostically it is often a valuable premonitory symptom. Hemophilia 
may produce severe nose-bleeding in 'children and is often recognized by this 
symptom. Epistaxis also occurs in purpura, scurvy, etc., and less frequently 
in Barlow's disease. As an accompanying symptom of general infectious dis- 
eases of childhood (measles, scarlatina) it is not so rare and in whooping- 
cough it is often important and serious. In the last affection, however, the 
blood which flows from the nose as well as from the mouth does not always 
originate from the nasal cavity, but from vessels located elsewhere which are 
ruptured in the severe paroxysms of cough associated with great cyanosis. In 
pertussis this hemorrhage is usually not prolonged, but when once it appears 
it may be repeated frequently during the acme of the disease. 

Epistaxis of older school-children requires special consideration. Baginsky 
quite correctly asserts that this may be regarded as a school disease, due to con- 
finement in the close air of the schoolroom together with the simultaneous 
mental exertion, and quotes Kotelmann, who found epistaxis in the higher 
grades of school much more frequently than in the lower (28.33 per cent. 



476 DISEASES OF THE NOSE 

against 12.16 per cent.). A likewise unquestioned, although insufficiently ex- 
plained, fact is the epistaxis of boys and girls at the time of puberty. In girls 
this bleeding sometimes appears with the menstrual period and is sometimes 
said to compensate for it. Stoerk believes that young men with nasal hemor- 
rhage have not practised coitus but suffer from sexual irritation. That there 
is a connection between the nose and the genital organs is unquestioned. How 
far epistaxis can be regarded as a sign of this relationship is a subject 
worthy of discussion but no longer belongs within the scope of infantile nasal 
diseases. 

The so-called spontaneous epistaxis, as has recently been proven (Michel, 
Kiesselbach, Chiari, and others) usually originates in an area of the cartilagi- 
nous septum which is so far forward that " the patient may reach it with his 
finger." Dust and other external agents cause itching, and excoriations are 
produced by the finger which lead to the rupture of a superficial vessel. The 
loosely formed thrombosis is readily dislodged by slight causes, but even with- 
out an obvious cause a further hemorrhage may occur. If the nose is examined 
with a speculum the suspected area is readily recognized by dilated vessels in 
the vestibulum nasi at the anterior end of the quadrangular cartilage (Mihal- 
kovicz, Chiari) ; rubbing with a pellet of cotton is often sufficient to start the 
hemorrhage anew. Under some circumstances deep ulceration may occur at 
this point and even perforation of the septum. 

Symptoms. — The symptoms of epistaxis require no special description. The 
blood usually exudes by drops, rarely in a stream. As a rule the quantity is 
exaggerated by the laity. Nevertheless, pallor, vertigo, and syncope are by no 
means rare, although the peculiar " fear of blood " plays a role in many chil- 
dren and such symptoms should not immediately be attributed to anemia of the 
brain from blood loss. The blood which flows along the posterior pharyngeal 
wall is often swallowed in considerable amounts and may afterward be vomited. 
The possibility of vomiting or the evacuation of masses tinged with blood after 
severe epistaxis should be mentioned to the parents. On the other hand, it 
should not be forgotten that in apparently spontaneous hemoptysis and hemate- 
mesis — also in nurslings with hemorrhagic discharges (see above) — the possi- 
bility of epistaxis is to be considered. 

Prognosis. — The prognosis of epistaxis in childhood is usually good. As a 
rule the loss in strength from profuse flow of blood is soon regained. 

Treatment. — The arrest of the hemorrhage and the prevention of its re- 
currence constitute the treatment of epistaxis. 

The first duty of the physician, when called to a case of nose-bleeding, is to 
quiet the frightened child and to convince the family, who perhaps are running 
about with sponges, vinegar, cologne water, etc., of the harmlessness of the 
condition. At the same time a brief examination of the pulse and the appear- 
ance of the patient assures him of the patient's general condition. With the 
child comfortably seated, or in a recumbent posture if syncope is threatened, 
the constricting collar and clothes are removed, the child is induced to breathe 
deeply and to restrain from blowing of the nose and coughing, and Bresgen ad- 



BLEEDING FROM THE NOSE (EPISTAXIS) 477 

vises also the avoidance of expectoration on account of the transitory stasis. To 
the child's care-takers is allotted the task of placing cold compresses upon the 
nose, the forehead, and the nape of the neck. In the meantime the physician 
has determined from which side of the nose the hemorrhage originates, for 
which a careful cleansing of the accessible parts is necessary. A thick tampon 
of cotton is then placed in the nostril and pressed against the septum. This 
alone is often sufficient to control the hemorrhage. If, following this provi- 
sional tamponage, blood appears from the other nasal opening or around or 
through the cotton plug, a piece of ice is placed into the bleeding cavity and 
enclosed with cotton. Hot water is equally of service. If this treatment is 
ineffectual, styptics may be employed, of which, however, only the Penghawar 
Djambi still possesses advocates. Sesqui-chlorid of iron which was at one time 
much employed has lost somewhat in favor on account of the possibility of cor- 
rosion, but might be tried, for a brief time only, in the commercial form of 
30 per cent, iron chlorid cotton. Eecently ferropyrin cotton has been strongly 
recommended (Lublinski, Breshen). More valuable than these styptics is the 
suprarenal substance in the form of adrenalin (adrenalin hydrochlorid, 0.1 to 
100 of water) and other combinations. Of this solution one part to nine of 
water is dropped upon cotton and pressed against the bleeding surface. Instead 
of water 2-5 per cent, of cocain or eucain may be employed, which not only in- 
creases the hemostatic effect of the adrenalin but also produces an agreeable 
sensation of relief. 

Less successful than the application of styptics with simultaneous compres- 
sion by means of cotton is cleansing of the nose with hemostatic solutions. 
This procedure may easily defeat the contraction of the vessels as the fluid 
removes the thrombus which may have formed. 

As a rule these measures will prove successful, but we must not omit an 
examination of the posterior pharyngeal wall to determine that the blood which 
has been stopped anteriorly by a tampon is not flowing off behind. If such 
should be the case, or blood soon reappears anteriorly, complete tamponage of 
the bleeding side of the nose must be performed. For this purpose iodoform 
gauze, or, better, iodoform-tannin or iodoform-collodion gauze, should be em- 
ployed, as the continuance of such tampons in situ for several days will prevent 
the decomposition of blood and mucus. Airol gauze is also recommended 
(Hanszel). The introduction is accomplished by a nose or ear forceps, a dress- 
ing forceps or grooved director. An attempt must be made to reach the choana 
so as to completely fill the nasal cavity. Chiari advises (for adults) three or 
four pieces of gauze 20 cm. in length and of the breadth of two fingers, folded 
in the middle, one end of which is carefully introduced into the nostril until it 
is firmly lodged in the bony structure of the nose. The remaining portion of 
the gauze is then folded in until the nostril is completely occluded. This tam- 
pon is kept in place one day and the coating of nasal mucus as a rule permits of 
its easy removal. 

As a last resort, in severe epistaxis tamponage by means of Belloq's tube, or 
a catheter or drainage tube may be employed. The tube is introduced through 



478 DISEASES OF THE NASOPHARYNX 

the nostrils and pharyngeal space into the mouth, where a tampon, correspond- 
ing in thickness to the patient's thumb, is fastened to the end and anchored in 
the choana. It is necessary to adjust it in position by the finger. This tam- 
pon is fastened anteriorly by means of the thread with which it was attached 
to the sliding instrument; some rhinologists fasten it in addition by a second 
thread which passes through the mouth. After clogging of the choana, tam- 
ponage of the anterior nasal cavity must be performed. This method is disa- 
greeable from the time it is instituted until removal of the tampon and should 
if possible be avoided in children. 

In hemorrhages which are not so severe that a minute inspection of the 
bleeding area is impossible, rhinologists now cauterize at once, thus combining 
arrest of the bleeding with a permanent cure of the epistaxis. This method is 
necessary in those relapsing cases of spontaneous epistaxis which originate from 
the area previously mentioned upon the anterior surface of the nasal septum. 
Cauterization is best practised with solid chromic acid or the galvano-cautery 
after anesthetization by cocain or cocain-adrenalin. Substances with a strong 
odor, such as trichloracetic acid or fuming nitric acid, had better be avoided in 
the child as they cause restlessness even before their introduction into the nose. 
The nose must not be blown after the cauterization and the cotton tampon must 
remain for one day. One or two applications are often sufficient for a perma- 
nent cure of the trouble. 

In the general treatment of children with a tendency to epistaxis a possible 
underlying affection, prevention of a secondary anemia, the avoidance of ex- 
cessive bodily and mental exertion, are of importance. School-children who 
suffer from frequent nose-bleeding should be kept from school for some time 
and perhaps altogether. Nose-bleeders should be cautioned against picking and 
scratching of the nose and the disagreeable habit should be overcome before un- 
pleasant consequences arise. 



DISEASES OF THE NASOPHAEYNX 

In accordance with the plan formulated at the beginning of this article this 
closes the discussion of the nasal diseases of infancy. There are other affections 
of the nose, as neoplasms, injuries, tuberculosis, cutaneous diseases, but none 
of these conditions is peculiar to infancy and their course is not different from 
that in adults. Also deformities and anomalies of the nose, especially of the 
septum, although congenital, are usually matters for later consideration and 
treatment, requiring the attention of a specialist, and thus are remote from the 
province of the general practitioner. 

We shall therefore pass to a discussion of diseases of the nasopharynx, 
which will be considered from the same standpoint as the pathologic conditions 
of the nose. 



ACUTE INFLAMMATION OF THE NASOPHARYNX 479 



ACUTE INFLAMMATION OF THE NASOPHARYNX; PFEIFFER'S 
GLANDULAR FEVER 

The maladies of the nasopharynx have a greater importance in infancy than 
at any other period. It is probable that the richness in lymphoid tissue of this 
region, that is, the ease with which swelling arises, which is peculiar to infancy, 
is the principal reason why these affections are mostly observed by the pedia- 
trist. 

Nevertheless the acute affections of the nasopharynx have not as yet been 
distinctly denned and occasionally a symptom-complex is presented which is 
not easy to diagnosticate. 

The difficulty of a proper recognition of such inflammatory affections in 
childhood, particularly in infancy, is enhanced by the awkwardness of local 
examination of the posterior nares; therefore it is obvious that together with 
the common and manifold inflammations of the pharyngeal structure, the fre- 
quency of acute diseases of the nasopharynx removes a large number of infan- 
tile affections from direct inspection, so that often merely a tentative diagnosis 
can be made. 

In view of these difficulties it seems proper to call attention to a diagnostic 
aid which is of value not only in the recognition but also in the localization of 
nasopharyngeal affections: acute swelling of the lymphatic glands of the nech. x 

The pharyngo-oral and pharyngo-nasal cavities are not only permeated by 
a profuse lymphoid tissue, known as Waldeyer's " tonsillar ring/' but also by 
an extensive plexus of lymph-vessels. The lymphoid or adenoid tissue is found 
in great aggregations, forming the " pharyngeal tonsil/' yet to be described, in 
the nasopharynx as well as in the tonsils, and is also present in the mucous 
membrane, for example, at the opening of the Eustachian tube. On the one 
hand, these adenoid elements form a suitable receptacle for infection and a 
common seat of inflammatory processes ; on the other hand, the numerous lym- 
phatic vessels cause a rapid absorption of irritative products and their con- 
duction into the adjacent lymphatic glands, which react with painful swelling. 
This rapid inflammatory involvement of the lymphatic glands at their root 
areas is a phenomenon peculiar to infancy, the cause of which has not been posi- 
tively determined. But the child does not react alike to all inflammatory affec- 
tions of the pharyngeal structure; the rapidity, intensity, and firmness of the 
lymphatic gland enlargement depends greatly upon the degree as well as the 
nature of the primary infection (for example, the characteristic hard lymph 
nodules in diphtheria). In many cases intumescence of the lymph glands does 
not occur, hut when it does arise we may expect a certain orderly arrangement 
whereby definite glands corresponding to every diseased portion of the naso- 
pharynx are always the first to enlarge. The knowledge of the relation of the 
individual regions of the nose and pharynx to the regional lymph nodules is 

1 Trautmann (Jahrbuch f. Kinderhk., 60, Bd. Ill) gives a comprehensive description 
of these conditions. 



480 DISEASES OF THE NASOPHARYNX 

therefore not to be under-estimated, and offers valuable diagnostic points of 
support. 

The important results obtained by anatomical investigation we owe — aside 
from the older reports of Mascagni, Sappey, and others — principally to Henle, 
Stahr, and Most. 

We learn therefrom that the region of the pharyngeal tonsil, the tonsils, 
and the base of the tongue possess a particularly profuse plexus of lymphatic 
vessels. In the nose the lower turbinated bones, the floor of the nasal cavity, 
and the choanae possess numerous lymph-vessels which become more scant in 
the septum, and are markedly decreased toward the entrance of the nose as well 
as in the upper turbinated bones and in the roof of the nose. The glandulae 
cervicales profundae superior es (Henle) are to be regarded as the essential 
outflow station of the lymphatic vessels from the pharynx and nasopharynx. 
These are situated at the point of bifurcation of the external and internal caro- 
tid arteries and follow the jugular vein to the base of the skull ; a well-defined 
lymph nodule is situated in the triangle formed by the jugular vein, the facial 
vein, and the lateral belly of the biventer muscle. Another group of deep cer- 
vical glands is situated laterally to the jugular vein upon the posterior scaleni 
muscle and the cervical plexus, and partially upon the posterior portion of the 
sternocleidomastoid. This important portion of the deep cervical gland group 
is designated by Most the glandulae cervicales profundae laterales; for the pos- 
terior portion the name gland of the nape of the neck is employed. In addi- 
tion, at about the height of the soft palate, on the boundary between the pos- 
terior and lateral walls of the pharynx and in front of the lateral portion 
of the rectus capitis there is one lymph gland, rarely more, which probably is 
in relation with the deep cervical glands just mentioned, but which deserves 
especial consideration on account of its constant situation. Most, who has 
called particular attention to it, has named it the pharyngeal gland. An in- 
constant accumulation of small but never numerous nodules is met with upon 
the posterior pharyngeal wall; these are designated glandulae retropharyn- 
geales. Most regards these merely as a passage to the pharyngeal and cervical 
lymph nodules. The submaxillary glands (eight to ten in number, Henle) 
are situated upon the inner surface of the lower jaw. The nodules situated be- 
tween the anterior bellies of the biventer muscle upon the chin are designated 
the submental glands. 1 

1 The role of the tonsil in causing adenitis and ready absorption is overestimated. 
These effects are mainly due to the function of " Waldeyer's lymphatic ring," and the 
accompanying pharyngitis. The lymph communication of the tonsil with the neigh- 
borhood is limited; affection of the tonsil when localized has very little influence in 
causing neighboring adenitis. When inflammation, or diphtheria of the tonsil extends 
beyond it, to the neighborhood, secondary adenitis will result to a higher degree. The 
finding of tubercle bacilli, diphtheria bacilli and cocci in the lacunae of the tonsil is no 
proof of their being absorbed and dangerous, just as little as the presence of bacilli and 
cocci in the nose means tuberculosis, or diphtheria, or toxemia. Microbes found in the 
tonsil are very apt not to be absorbed, for good anatomical reasons, but to be expelled 
again on the road they came on. [Arch, of Pediatrics, June, 1907.— Editor.I 



ACUTE INFLAMMATION OF THE NASOPHARYNX 481 

In what relation are these glands to the region of the lymphatic vessels 
of the different portions of the pharynx and of the posterior nasal cavity? 

The post-pharyngeal lymph-vessels as well as those of the lateral and upper 
portions of the pharynx permeate the pharyngeal wall, first touching the retro- 
pharyngeal glands, mentioned above, and then the glandulae pharyngeals 
(Most). Thence they pass to the deep cervical glands (glandulae cervicales 
profundus superiores), to which also some vessels pass directly. A portion of 
these lymph-vessels, and particularly those which originate from the upper 
portion of the nasopharynx and va^ult of the pharynx, pass directly to the lat- 
eral cervical glands (glandulae cervicales profundus laterales), avoiding the 
pharyngeal gland. The lymphatic vessels of the tonsils and palatine arches 
pass immediately to the deep cervical glands and especially to that nodule, 
mentioned above, which is situated in the triangle between the jugular and 
lateral facial veins and the biventer muscle. The lymph-vessels of the lower 
portion of the pharynx and the region of the larynx (Most) as well as of the 
upper portion of the thyroid gland (Bartels) have their stations in the glandu- 
lae cervicales profundae superiores. 

Supplementarily a few other root regions of lymph glands upon the neck 
will be mentioned. 

The lymphatic vessels from the anterior portion of the nose and the septum 
empty in part into the facial gland situated upon the parotid, partly into the 
submaxillary gland. The lymph from the interior nose makes its way poste- 
riorly through the choanae and thence in part directly to the deep cervical gland, 
in part — conjointly with the lymph-vessels of the posterior pharyngeal wall — 
first to the glandulae pharyngeales. The lymph-vessels of the buccal mucous 
membrane (Polya and Navratil), as well as those of the mucous membrane of 
the upper jaw, empty largely into the submaxillary gland; only a small por- 
tion pass directly to the deep cervical gland. Upon the lower jaw one portion 
passes to the submaxillary gland, another to the submental gland. The shin 
of the cheeks has its lymph station in the parotid, submental, and partly also 
in the submaxillary glands. The lips (Dorendorf) empty their submucous 
lymph-vessels into the submaxillary gland, their subcutaneous lymph-vessels 
partly (upper lip) into the submaxillary gland and partly (lower lip) into the 
submental lymph gland. From the tongue the lymph tracts pass into the sub- 
maxillary gland, the glandulae cervicales profundae, and the glandulae men- 
tales (Kiittner, Jordan, Porier). 

The following are the results of this anatomical presentation, which are of 
practical importance as regards the pathologic enlargement of the glands : 

Swelling of the submaxillary gland, which is not found at the angle of 
the jaw but upon the inner side of the lower jaw, arises from disease of the 
buccal mucous membrane, the gum of the lower jaw, the upper lip and the 
tongue, or the skin of the cheek, but not from disease of the pharynx. In en- 
largement of the submental gland an affection of the mucous membrane of the 
lower jaw, as well as of the lower lip, is to be considered. If the pharyngeal 
glands are enlarged, disease of the posterior pharyngeal wall, principally of the 
32 



482 DISEASES OF THE NASOPHARYNX 

middle area, as well as of a portion of the internal nose, may be assumed. On 
the other hand, in affections of the upper portion of the pharynx, therefore also 
of the nasopharynx, the lateral deep cervical glands (including the glands of 
the nape of the neck) will be found enlarged, and may be felt below and behind 
the sternocleidomastoid muscle. In inflammation of the tonsils and of the 
palatine arch an enlarged nodule will be discovered at the bifurcation of the 
facial and jugular veins, in front of the sternocleidomastoid muscle, at about 
the height of the hyoid bone. The deep cervical glands will also be enlarged 
and may readily be felt in the furrow in front of the sternocleidomastoid and 
below it. The last-named glands will be found intumescent in severe inflam- 
matory processes in the deeper regions of the pharynx, in the laryngeal area 
as well as in the upper portions of the thyroid gland. In addition they are 
the terminal stations of a number of other lymph-gland regions of the neck and 
will be found enlarged in all inflammatory processes of the nasopharynx and 
the pharynx. 

A knowledge of these facts permits us to form an opinion from the acutely 
enlarged lymph-glands as to the seat of the primary affection and therefore 
contributes valuable auxiliary aid in the recognition of acute inflammations of 
the upper arr passages. 

After this excursion into the anatomical precincts, which I do not believe 
to be superfluous, the clinical aspect must be considered, and first in order are, 
the acute inflammations of the nasopharynx. 

A differentiation may be made between artificial and idiopathic inflam- 
mation : 

Artificial infections of the nasopharynx, although rare, are the consequence 
of operative removal of adenoid vegetations. As a rule this operation is not 
followed by secondary phenomena, that is the process of healing remains 
strictly local, as is usually seen also after tonsillotomy. In rare cases, however, 
there are apparently deep-seated inflammatory processes which, in their final 
result, are mostly harmless, but which present a quite characteristic picture. 
The most prominent symptom of this secondary infection is painfulness of the 
cervical region, which enforces a rigid fixation of the head (Thost). In passive 
movements of the head there is a lively counteraction similar to the condition in 
meningitic children with rigidity of the neck. This painful tension of the neck 
musculature, however, more closely resembles muscular rheumatism, especially 
when it is unaccompanied by fever. The early objective examinations of such 
children show but little. Inspection of the pharynx merely reveals a down- 
ward flow of mucus along the posterior wall of the pharynx, as is common after 
adenoid operations, and in one of my cases even posterior rhinoscopy and digi- 
tal examination of the nasopharynx by an expert gave a negative result. Care- 
ful palpation of the nape of the neck is liable to reveal the condition earliest, as 
we can thus determine whether the bellies of the muscles are less painful than 
the furrows between them. This palpation fs also of decided value if we are 
able to demonstrate an enlargement of small pearl-like glands of the neck be- 
hind the sternocleidomastoid. 



ACUTE INFLAMMATION OF THE NASOPHARYNX 483 

It has been indicated that the enlargement of these glands in particular 
signifies an affection of the nasopharynx, and this enlargement, therefore, in 
conjunction with the history, may be regarded as positive evidence of an inflam- 
matory infection following operation. In the case quoted above there was a 
sudden discharge of pus from the nose from a region which could not be de- 
tected by rhinoscopy, from which the child soon recovered. Moderate fever was 
present during the prevalence of the lymph-gland enlargement. 

Xotwithstanding its rarity, this form of post-operative inflammation of the 
nasopharynx has been considered in detail because it aids our understanding 
of the idiopathic inflammation of this region. 

This disease asserts itself as follows : A child formerly healthy, or who has 
previously shown a similar condition, is suddenly attacked by high fever 
(40° C.-104° F.), pain in the limbs, vomiting and headache, as in follicular 
tonsillitis. The tongue is coated and there is complete loss of appetite. The 
early examination reveals but little and inspection of the pharynx especially is 
unsatisfactory. 

It is true, the posterior pharyngeal wall, if it can be examined at all, ap- 
pears inflamed, but the tonsils and palatine arches are normal or are so slightly 
injected that they cannot be the source of the pyrexia. Speech is sometimes 
conspicuously nasal, as in occluded nose, but there is neither impermeability 
nor coryza, nor does the otoscopic examination reveal anything of importance. 
The tympanic membrane is either normal or moderately injected. 

This obscure and disturbing condition may continue for some days without 
change ; often, however, a new symptom is added, which is not calculated to re- 
assure the parents. The child complains of pain in the throat, localized, if it 
is sufficiently intelligent, to the nape of the neck, not as the pain of swallowing. 
As a matter of fact the neck is sensitive to pressure and its movability is hin- 
dered. Palpation of the neck, especially of the nape, now often shows positive 
findings: Along the posterior border of the sternocleidomastoid muscle, on 
one or both sides, are found a number of small, painful glands, corresponding 
to the glandulae cervicales profundae laterales and the glands of the nape 
of the neck. Simultaneously, or soon afterward, enlargement of the deep 
cervical glands below the belly of the sternocleidomastoid is noted. With 
enlargement of these glands in many cases the acme of the disease is reached 
and the fever declines rapidly. Sometimes, however, there are relapses, the 
temperature remaining high. The glands increase in extent and size, but final 
recovery may be confidently expected. Suppuration of the glands does not 
occur. 

To the expert it is clear that this is the clinical picture of a disease known 
as Pfeiffer's glandular fever, which has been much discussed in pediatric 
literature. Pfeiffer, in his description, has especially mentioned the enlarge- 
ment of the glands at the nape of the neck behind the sternocleidomastoid, re- 
sembling a rosary, as a characteristic feature of the affection, and says literally: 
" Also the glands situated anteriorly to the sternocleidomastoid are often in- 
volved in the process, but their enlargement and painfulness is not character- 



484 DISEASES OF THE NASOPHARYNX 

istic, as they are enlarged and painful in many other affections, for example, in 
tonsillitis, stomatitis, etc." 

Heubner, however, in a supplement which he contributed to Pfeiffer's origi- 
nal communication, has extended this view by including cases in which " the 
lymph glands situated below the sternocleidomastoid " greatly enlarge, with 
fever and a rigidity of the head, without any demonstrable affection in the 
mouth, pharynx, or elsewhere. In subsequent reports regarding this affection 
a sharp distinction is not made between the acutely swelling glands, and Hoch- 
singer, whose views coincide in the main with those given here, in a reference 
to Pfeiffer's publication, speaks particularly of an enlargement of the " cervi- 
cal or submaxillary " lymph-nodules. 

From the foregoing presentation of the relations of the lymphatic glands of 
the neck it seems absolutely desirable to limit the pathologic picture, somewhat 
more sharply than was previously done, to enlargement of the lateral cervical 
glands, and to regard this as a sign of disease of the upper part of the pharynx. 
In the further course of the affection the deep cervical glands also enlarge, but 
never the submaxillary lymph-nodules. 

The above clinical picture, which corresponds with the original description 
of Pfeiffer's glandular fever, may therefore be referred directly to an acute 
inflammation of the nasopharynx, and coincides also with that form of dis- 
ease which proceeds from a post-operative inflammation in this region. 

We have not considered the role played by adenoid pharyngeal vegetations— 
the so-called Luschka's tonsil — in the occurrence of these acute inflammations 
of the nasopharynx, as it is desirable to adhere chiefly to the localization of 
diseases in the pharyngonasal cavity. There can be no doubt, however, that 
such an inflammatory process without involvement of the pharyngeal tonsil is 
improbable and that acute inflammation of the retronasal space principally rep- 
resents an inflammation of adenoid vegetations. 

This is favored by the anatomical relations, by the tendency of the lym- 
phatic tissue to inflammation and to retention of mucus and secretion, and, 
finally, by clinical experience. The last teaches that children with an enlarged 
pharyngeal tonsil not only show a particular tendency to inflammation, in the 
form of Pfeiffer's glandular fever, but that in such children relapses of this 
acute disease of the retronasal mucous membrane form the rule, and that re- 
moval of the adenoid growths often brings about permanent recovery. 

These relapsing inflammations of the nasopharynx are often worse than 
relapsing tonsillitis and are an actual plague to patient and physician, as it is 
impossible for the latter to demonstrate the true seat of the disease to the 
parents of the child, and his diagnosis is therefore readily mistrusted. These 
children may have four, five, and even more, attacks of puzzling fever in a 
winter and may also markedly emaciate from the accompanying loss of appe- 
tite. In relapsing retronasal inflammation the glands of the nape of the neck 
as well as the cervical glands are enlarged. All of these considerations justify 
the view, expressed above, that the clinical picture, under the name of Pfeiffer's 
glandular fever, represents an inflammation of the pharyngeal tonsil. On this 



ACUTE INFLAMMATION OF THE NASOPHARYNX 485 

point we agree implicitly with Hochsinger, who, some years since, promulgated 
the same opinion in a lecture. 

What are the causes of this acute inflammation of the nasopharynx? As 
we are here dealing principally with a disease characterized by its localization, 
it is likely that different causes may bring about the same pathologic result. 
One of these — post-operative infection — has already been mentioned. Scarla- 
tina might also produce a like pathologic picture, which may give rise to 
diagnostic perplexity if it appears during the time of defervescence. , It is 
exceedingly likely that influenza is also an etiologic factor for this form of in- 
flammation. Finally — and on this great stress must be laid — retronasal acute 
inflammation, or Pfeiffer s glandular fever, so often appears cumulatively that 
it immediately gives the impression of a substantive infectious disease. 
Pfeiffer emphasizes this cumulative appearance of the affection — even in house 
epidemics — and for this reason considers it a nosologic entity, distinct from 
other diseases of the glands of the neck. So far as is known there are no re- 
ports of bacteriologic investigation but it is not unlikely that the bacillus of 
influenza is responsible for the entire condition. 1 

Finally, a few words regarding the varieties of acute retronasal inflamma- 
tion. 

Pfeiffer and other more recent authors have demonstrated that the transi- 
tory fevers of children, the " ephemera " or " febricula," to which, as " Fievre 
ephemere," a special chapter in the Traite des Maladies is devoted, are often 
abrupt forms of these retronasal inflammations, which seems quite plausible. 

In contrast thereto are the curious general infections following glandular 
fever, which run their course with enlargement of the spleen, liver, and retro- 
peritoneal lymph glands, and intestinal disturbance. Heubner has also men- 
tioned nephritis as a severe complication of the disease. We will not enter 
upon a detailed description of these perplexing clinical cases. Several con- 
ditions which appear to me to be unrelated to the affection have been included, 
and, as has already been indicated, the clinical picture of retronasal inflamma- 
tion can be produced by various underlying affections. Perhaps the relation 
between the lymphatic pharyngeal ring and the lymphoid tissue of the vermi- 
form appendix, which has lately been disclosed, will render more intelligible 
some further enigmatic complications of " Pfeiffer's glandular fever." 

From the foregoing, however, we recognize in the acute inflammations of 
the nasopharynx, particularly when occasioned by adenoid vegetations, an im- 
portant affection of infancy, a knowledge of which is of great value to the phy- 
sician, who otherwise is liable to commit many diagnostic errors. Professional 
skill is usually of little avail, particularly as local treatment of the child is 
almost impossible; in retronasal inflammations of this kind we are limited to 
general remedies for control of the fever, compresses to the neck, frequent 
cleansing of the nose, applications of astringent antiseptic solutions to the pos- 
terior pharyngeal wall by way of the nostrils. The treatment of this affection 

1 Trautmann (Jahrbuch f. Kinderhk., 60, Bd. Ill) in one case demonstrated strep- 
tococci. 



486 DISEASES OF THE NASOPHARYNX 

coincides in the main with that of adenoid vegetations, and, in the relapsing 
forms particularly, there should be no delay in the removal of such prolifera- 
tions. 

Having considered acute inflammations of the nasopharynx it would now be 
proper to discuss the chronic inflammatory processes of this region. 

Clinical considerations, however, seem to make it more proper to include 
the chronic inflammations of the pharyngonasal cavity in the description of 
adenoid pharyngeal vegetations. The latter not only constitute the most com- 
mon and positive cause of chronic nasopharyngeal disease but one is an ana- 
tomical transition of the other, so that they can scarcely be separated clinically ; 
it is usually difficult to determine where the signs of simple " adenoids " termi- 
nate and those of the associated catarrh begin. Chronic inflammation of the 
nasopharynx without hypertrophy of the adenoid tissue is such an accidental 
occurrence in practice that it may be left out of consideration altogether. We 
shall therefore pass to a discussion of 



ADENOID VEGETATIONS IN THE NASOPHARYNX 

If a historian were to chronicle the events of medicine from the standpoint 
of the momentous changes which a single personage has often brought about in 
the various realms of science he would scarcely find a more characteristic ex- 
ample than the development of our knowledge of adenoid vegetations of the 
nasopharynx. 

Existing for centuries, distributed over all parts of the world, described, as 
regards their consequences, by shrewd investigators, but not themselves recog- 
nized, this form of disease was completely revealed and almost exhaustively 
described through the faculty of observation of a single man, and soon became 
an exceedingly fertile field of labor for the medical practitioner, forming to- 
day a valuable permanent asset of professional knowledge and activity. 

Dupuytren had previously described a pathologic picture consisting of oc- 
clusion of the pharynx and evinced surprise that tonsillotomy did not bring 
about a cure. Czemak, the inventor of the laryngoscope, gave a rhinoscopfc 
description of the proliferations without entering into the subject further. 
Voltolini even performed an operation for adenoids which was successful. 

Other authors also had occasionally referred to anomalies in this region, 
but to a Danish otologist, Dr. William Meyer of Copenhagen, belongs the un- 
disputed merit of first recognizing the connection of the clinical picture with 
the anatomical condition, and of fully understanding the great importance of 
the former. After his first report in the Danish language (1868) he studied 
the affection further and in 1873 published a description of the disease in a 
German periodical, and twenty years later (1893) he enriched the pathology 
of the affection by valuable communications. Not only did he discover that 
the adenoid pharyngeal vegetations were an exceedingly important affection of 
infancy, but he energetically endeavored to increase our knowledge of the con- 



ADENOID VEGETATIONS IN THE NASOPHARYNX 487 

dition. The service which Meyer has rendered toward the bodily and mental 
welfare of our children is extraordinary, and the erection of a monument in 
Copenhagen by his compatriots since his recent death has proved that their 
esteem for a promoter of the health of the human race is just as great as is 
that for the victorious generals and successful statesmen in other countries. 

What has subsequently been written upon adenoid vegetations is legion. 
An aifection that is so enormously frequent, that presents such readily recog- 
nized symptoms, that offers such a beneficial object of professional activity, 
must naturally engage the interest of the medical world in a high degree and 
offer rich stimulation to supplementary clinical knowledge, to pathologic study, 
and to operative procedures. To recount this vast amount of literature is im- 
possible and superfluous. Only the most important points will be mentioned, 
which are sufficient to give a clear picture of the disease according to our pres- 
ent knowledge, and to show in how many directions Meyer's creative thought 
has had a fructifying effect upon medical investigation. 

For a better understanding of the symptomatology we shall begin with the 
anatomical basis of the affection. 

The pharynx, as is well known, is rich in lymphoid tissue which is not ex- 
clusively localized to the tonsils, the base of the tongue, and the pharyngeal 
wall, but is also very profuse in the pharyngonasal cavity. This tissue is found 
not only at the tubal openings and in the mucous membrane but it also accumu- 
lates, particularly at the roof of the nose, into a semi-globular mass which is 
designated the pharyngeal tonsil or LuschTca's tonsil. When proliferation of 
this lymphatic tissue occurs the pharyngeal tonsil, as a rule, is primarily 
affected, but the remainder of the lymph-tissue of the nasopharynx also en- 
larges (Hopmann, B. Fraenkel, and others), as is usually the case with the 
other structures of the lymphatic ring which participates in this hypertrophy, 
especially the tonsils. 

If, as is frequently done, the disease is designated merely an "enlarge- 
ment" or "proliferation of the pharyngeal tonsil," the extent of the affection 
anatomically is not exposed, but that change is indicated which principally 
produces the clinical phenomena and the relief of which is sufficient to bring 
about recovery. From this description it is evident that in adenoid vegetations 
we are not dealing with new structures but that it is chiefly the proliferation 
of a physiologic tissue and the tendency of the same to inflammatory processes 
which produces the morbid phenomena. The conception of an " enlargement " 
of the pharyngeal tonsil is naturally not sharply defined. If the proliferation 
is so extensive that the entire pharyngonasal cavity is filled, that perhaps the 
lower pole of the tumor attains the height of the palate, there can be no doubt 
of its pathologic importance. On the other hand, with slight enlargement, the 
opinions regarding the importance of the changes may be divided; very often 
from the clinical symptoms only will we be able to decide whether the pharyn- 
geal tonsil is pathologically enlarged and must be removed, or whether it is of 
normal size. The pathologic significance, therefore, lies not in the growth it- 
self, which does not require extirpation as does a growing fibroma or sarcoma, 



488 DISEASES OF THE NASOPHARYNX 

but in the relation of the same to its surroundings, in filling the nasopharyngeal 
space; a plug of cotton embedded in this region would produce similar symp- 
toms. It is true, not merely the symptoms of occlusion of the nose occur, but 
also a stasis of secretion and irritative phenomena of the mucous membrane of 
the nasopharynx, and with these secondary symptoms which are so intimately 
associated with the adenoid vegetations that they should be included among the 
essential factors of the same. 

Enlargements of the adenoid nasopharyngeal tissue is a widely distributed 
and exceedingly common affection. W. Meyer conducted ethnographic studies 
relative to this point and made the surprising discovery that adenoid growths 
are present in Indians, Chinese, and Greenlanders likewise as in Europeans and 
in the mixed races of North and South America and India. It is generally as- 
sumed that the disease is more prevalent in cold, damp regions than in climates 
which are warm and dry; Korner, for example, gives higher figures for the 
Baltic Sea-coast than for the interior country. 

In regard to the frequency of adenoid vegetations there are contradictory 
reports. Meyer estimated 1 per cent, of such cases in school-children — a figure 
which, in a previously unknown disease, must have seemed high. Kafemann 
found the affection among school-children in 7.8 per cent, of the boys and 10 
per cent, of the girls. Schnuckmann demonstrated adenoid vegetations in 30 
per cent, of the pupils, and Felix's figures range between 28.52 per cent, and 
35.10 per cent. Korner calculates the number of cases in children living along 
the sea-coast as 36 per cent., and in 26 to 28 per cent, of those residing inland. 
The specialist in diseases of children will be inclined to agree with the higher 
rather than with the lower estimates as these statistics were obtained from 
school-children, while experience demonstrates that adenoid vegetations are 
present even in infancy and that with advancing age the growth has a tendency 
to involution rather than to enlargement. If these statistics had been extended 
to smaller children very high percentages would have been obtained. Com- 
pilations regarding the prevalence of adenoid vegetations between infancy and 
puberty would be of great value, as they would prove, as experience appears to 
indicate, that there is first a rise and then a decline in the frequency of the 
pathologic picture produced by adenoid growths. 

Is there a congenital enlargement of the pharyngeal tonsil? This is a 
debated question, although there is much to favor the affirmative. In nurslings 
we find symptoms which indicate adenoid vegetations, and it is often learned 
that one of the parents suffered from like symptoms during childhood. A fa- 
milial tendency to adenoids is not rare, and here we occasionally observe that 
only those children are affected who resemble the parent who had suffered from 
the same condition. In ancestral picture galleries the typical facial expression 
of marked adenoids may be followed from generation to generation. In favor 
of congenital adenoids is the association of other anomalies in the formation 
of the face (see below) which can scarcely be regarded as mere sequelae of 
obstructed nasal respiration. For these reasons we must coincide with those 
authors (B. Fraenkel, Semon, Lublinski, and others) who regard adenoid vege- 



ADENOID VEGETATIONS IN THE NASOPHARYNX 489 

tations, often at least, as a congenital anomaly, and therefore we are not con- 
cerned with a " proliferation " but with a " hyperplasia " of the pharyngeal 
tonsil. Nevertheless, it is unquestioned that chronic coryza, as well as infec- 
tious diseases which run their course with special implication of the upper air 
passages, have a deleterious influence upon the lymphoid tissue of the naso- 
pharynx, in that they first give rise to swelling, or, if the pharyngeal tonsil is 
already enlarged, chronic inflammatory processes arise and thus stimulate 
hypertrophy. Here probably similar conditions are operative as are readily 
apparent in the faucial tonsil. 

Symptomatology. — In the clinical picture of adenoid vegetations, there are 
numerous characteristic factors which, singly or conjointly, at first glance often 
raise a justified assumption of the existence of an enlarged pharyngeal tonsil. 

Only in infancy can there be errors in diagnosis; then the symptoms are 
less exact and examination by means of the finger or the rhinoscope is difficult 
to accomplish. The frequent recurrence of coryza with a tendency to chro- 
nicity, snoring, the early appearance of aural catarrh, as well as difficulty in 
nursing, are always suspicious symptoms which, often from the first months of 
life, permit a tentative diagnosis of adenoid vegetations. In such infants the 
characteristic phenomena often develop to such an extent that extirpation of 
the growth becomes necessary as early as the sixth or ninth month of age. We 
are less inclined to associate laryngospasm or " suffocation " of children, that is, 
the sudden arrest of respiration, with proliferation of the pharyngeal tonsil. 
The nature and course of these attacks, their frequent combination with rickets, 
the often prompt effect of phosphorus treatment, all justify in laryngospasm 
the assumption of an acute, nervous, pathologic condition rather than of an 
affection due to a permanent anatomical change. Even in those cases in which 
the expiratory form of laryngospasm, the suffocation above-mentioned, exists as 
a permanent symptom, lasting until the second or third year of life, the extir- 
pation of such adenoids as may be present is by no means followed by that 
prompt relief which should be expected with an existing relationship. 

In older children the symptoms of the affection are unmistakable. 

According to the degree of enlargement of the pharyngeal tonsil the nasal 
respiration is partially or wholly inhibited. This stenosis of the nasopharynx 
almost exclusively forces the respiration through the mouth. On account of 
the constantly open mouth such children are in frequent dispute with their 
associates, who regard the symptom as a bad habit and constantly remind them 
to close the mouth. Smaller children, who have not been weaned from the 
breast or bottle, take their food in brief draughts and become very restless. 
Many seeming faults of the wet-nurse, particularly an insufficient quantity of 
milk at each feeding, may perhaps be referred to adenoid vegetations. Larger 
children eat hastily in a constant endeavor to free the mouth, the consequences 
of which are incomplete mastication and the swallowing of large particles of 
food. There is sometimes shortness of breath in speaking, which, although less 
prominent than the disturbances of speech yet to be mentioned, is nevertheless 
disagreeable. With severe nasal occlusion this dyspnea becomes very conspic- 



490 DISEASES OF THE NASOPHARYNX 

nous when ascending steps and in prolonged walking and may simulate a 
direct symptom of disease; thus I know of a boy who was taken away from 
school on account of a " cardiac defect/' in whom nothing was found but ex- 
tensive adenoid vegetations. This inhibited nasal respiration may in mild 
cases be only slightly prominent and very frequently is transitory. When ade- 
noid proliferations which hitherto have not seriously interfered with nasal res- 
piration, become enlarged from coryza or cause the retention of secretions, the 
clinical picture of nasal stenosis arises and may create a quite serious dis- 
turbance. 

In addition, the enlarged pharyngeal tonsil may itself he the seat of a 
catarrhal inflammation of the mucous membrane, which, as was mentioned pre- 
viously, is revealed by high fever of several days' duration with secondary en- 
largement of the lymph glands of the neck, or by a chronic catarrh. The latter 
condition chiefly involves the mucous membrane of the pharynx, producing an 
irritation which results in a constant rasping, cough and expectoration. This 
is often thought to be a naughty trait, for which the child is punished. Inspec- 
tion of the pharynx in such cases will show the posterior pharyngeal wall to be 
reddened and frequently granulated (pharyngitis granulosa), with a trickling 
mucopurulent secretion which readily accounts for the " naughtiness " and 
" hysterical cough." 

Besides this chronic irritative condition, in which the pharyngeal organs 
may participate through adenoid vegetations, these growths are occasionally 
also the immediate cause of acute inflammation of the pharynx itself. Thus, in 
relapsing tonsillitis, vegetations in the nasopharynx should always be thought 
of as they retain the infectious secretion which from time to time reaches the 
tonsils. In these conditions experience has shown that tonsillotomy alone 
does not always relieve, and that only the removal of the adenoids will prevent 
a recurrence of these inflammations. 

The internal portions of the nose may be involved in a similar manner. 
By propagation of the catarrh from the pharynx to the nose swelling and red- 
ness of its mucous membrane occurs, especially upon the erectile tissue of the 
turbinated bones, giving rise to that condition designated by rhinologists rhi- 
nitis hypertrophica. The lower turbinated bone may decidedly occlude nasal 
communication so that the inspiration of air is interrupted within the nose be- 
fore the obstruction in the nasopharynx is reached. This combination of ade- 
noid vegetations and hypertrophy of the turbinated bones is of highly practi- 
cal interest, for, as Heermann correctly asserts, it may happen that not until 
extirpation of the adenoids and the continued existence of the affection will the 
greater obstruction in the nose be sought and found. Other diseases of the 
nose are familiar to the specialist as accompanying phenomena of adenoid pro- 
liferations, the symptoms of which are principally a muco-purulent nasal dis- 
charge and a deficient sense of smell. 

The sequelae of this nasal affection, which may readily be misunderstood, 
are eczema, fissures, swelling of the upper lip, which are so common with a 
profuse purulent flow from the nose. A diagnosis of scrofula is then apt to be 



ADENOID VEGETATIONS IN THE NASOPHARYNX 491 

made and, based on this view, together with the frequent irritative condition of 
the respiratory organs and the enlargement of the lymph glands, next to be 
described, the assumption is raised that the adenoid proliferations are the ex- 
pression of a scrofulous diathesis. That this view is not correct will be decided 
later. 

In the description of acute inflammations of the nasopharynx attention was 
called to the importance of the enlargement of the superficial cervical glands, 
including those of the nape of the neck, in the diagnosis of such conditions. 
It is evident that from the acute swelling in chronic irritative processes of this 
region chronic intumescent lymph-glands may develop, and as a matter of fact 
chains of pearl-shaped enlarged lymph-nodules behind the sternocleidomastoid 
(glandulae cervicales laterales), associated with catarrhal irritation, are the 
most common accompanying symptoms of such adenoid vegetations. As, how- 
ever, the nose, the pharynx, and the skin of the lips may be the site of long- 
continued inflammatory phenomena, all of the glands may swell whose root 
area corresponds to these regions, and thus a well-simulated scrofulous clinical 
picture is produced. Even after extirpation of the adenoids and under favor- 
able circumstances some time is required for the glands to return to their nor- 
mal size. 

The ear suffers to a great extent on account of the vicinity of adenoid 
vegetations. Xot only is the opening of the Eustachian tube permanently or 
transitorily occluded by the proliferations and the entrance of air into the ear 
inhibited, but catarrhal processes from the pharyngonasal cavity are readily 
conducted to the tympanum. This is a serious consequence of adenoid vegeta- 
tions, the full importance of which can be best realized from an expression of 
Mackenzie's that the discovery of adenoid growths has saved at least 100,000 
persons from deafness. As a matter of fact, disturbances of hearing are pres- 
ent, according to Abeles, in 57 per cent., according to Halbeis in 7-1 per cent. 
(Hartmann and "W. Meyer) of patients with adenoid vegetations. The oft- 
recurring acute diseases of the ear in the course of coryza must particularly 
awaken the suspicion of adenoid vegetations, which, on account of the severity 
of the possible sequels, require a radical treatment more than any other symp- 
tom of the affection. In scarlatina these proliferations may be of ominous im- 
port, for at least they favor the appearance and prolong the cure of an aural 
process. 

The larynx and bronchi are among the organs which may be irritated 
through the presence of an enlarged pharyngeal tonsil. An important factor in 
the development of a laryngeal catarrh is the propagation of chronic catarrh 
from the nasopharynx, due to the deficient nasal breathing, whereby a valua- 
ble protective measure for pulmonary respiration is lost. As the air passes 
through the nose it is cleansed of the grosser admixtures, is warmed, and finally 
is saturated with moisture (Bloch and others), all of which processes are abol- 
ished when nasal respiration is inhibited. The result of these conditions when 
adenoid vegetations are present is the frequent occurrence of pseudo-croup, 
as well as the ready appearance of febrile bronchial catarrhs. I know of a boy 



492 DISEASES OF THE NASOPHARYNX 

aged four years who, every few weeks for two winters, had an acute bronchial 
catarrh, almost asthmatic in character, associated with high fever, which was 
immediately and permanently relieved after nasopharyngeal proliferations were 
removed. In children who " cough the entire winter," who have frequent 
attacks of bronchitis and sometimes a circumscribed pneumonia, it is well to 
inform ourselves in regard to the nasal condition before speaking of " affected 
lungs " or " beginning catarrh of the apex." Blood-tinged nasal mucus not 
infrequently may simulate pneumonic sputum. 

The symptoms of adenoid proliferation which have been described are in 
direct relation with the anatomical changes in the nasopharynx and its sur- 
roundings. 

We shall now pass to the other accompanying symptoms of the affection 
which are of scarcely less importance for the development and health of the 
child. 

A change in the facial expression under some circumstances is a very 
striking feature of the disease. With a normally closed mouth the tongue 
forms a sort of suction valve which tends to uphold the lower jaw. When nasal 
respiration is inhibited and the mouth remains open this suction power is 
absent and the lower jaw drops mechanically. The face is then elongated, the 
nasolabial folds obliterated, the expression is less animated ; briefly, an appear- 
ance anything but intelligent is produced which, in combination with the men- 
tal condition of these children, soon to be described, appears to justify a low 
estimate of their intellect. This stupid physiognomy is very characteristic and 
when well-marked at once reveals to the expert the presence of adenoid vegeta- 
tions ; even in antique statuary and in old portraits this sign of adenoid vege- 
tations has been observed. 

A peculiar and as yet unexplained sequel of marked adenoid vegetations is 
deformity of the upper jaw. The bone is narrowed, higher, and forms an acute 
angle anteriorly, causing displacement of the teeth. How this malformation of 
the jaw arises is very questionable. Some authors regard it as a sign of de- 
generation, which naturally would also favor a congenital existence of adenoids. 
Other investigators regard it as the mechanical effect of constant mouth breath- 
ing upon the growing bone (Bloch, B. Fraenkel, etc.) and still others see 
therein a compensation for the retarded nasal development (Korner, Abeles). 

That disturbances in the growth of the nose also occur from adenoid vege- 
tations has been maintained by various authors. 

Flattening of the thorax and deviation of the vertebral column, which has 
been described by a number of writers as a consequence of adenoid vegetations, 
is just as unintelligible and uncertain, but is probably the connecting link of an 
existing rachitis. Ziem has attempted to produce this deformity experiment- 
ally by sewing together one of the nasal openings in young cats, which was fol- 
lowed by scoliosis. Naturally these deformities of the thorax add to the dis- 
turbed respiration of children who suffer from an enlarged pharyngeal tonsil. 

Change in the speech is a further factor which at once denotes adenoid 
vegetations. It has already been mentioned that a certain haste in speaking and 



ADENOID VEGETATIONS IN THE NASOPHARYNX 493 

a disinclination to talk are sequels of the dyspnea due to occluded nose. More 
important and characteristic is the speech itself. Such children are often very 
late in learning to talk ; for a long time they mumble their words, the nasal 
as well as the guttural sounds being indistinct. The principal feature, however, 
is the lack of timbre in the speech, which is brought about by the resonance in 
the nasopharyngeal cavity, so that a monotonous drone results (" dead speech," 
W. Meyer). Stuttering also is associated with adenoid vegetations in some 
cases. These disturbances of speech are not only significant factors in the 
recognition of the aifection but are also an important indication for the special- 
ist in speech disturbances, who very often must begin the treatment for delayed 
speech, stammering, or stuttering by removal of adenoid growths. 

Whether the headache which is so common in children with adenoid vege- 
tations is to be referred to an irritation of the nerve trunks adjacent to the 
nose, to affections of the auxiliary cavities, which in the child are but slightly 
developed, to swelling of the nose, to venous stasis of the vessels of the head, 
or to overloading of the blood with carbonic acid, as is maintained by many 
authors, cannot be answered. It is certain, however, that this disagreeable 
affection sometimes disappears rapidly after extirpation of the growths. 

The headache or sensation of pressure upon the forehead, the difficult res- 
piration, the disagreeable sensations in the nose, the dulness of hearing, and 
perhaps also a hindrance in the off-flow of intracranial lymph (Guye) com- 
bine to produce a peculiar mental condition in children with extensive adenoid 
vegetations which Guye has designated aprosexia nasalis, and to which Bresgen 
has drawn attention in the condition of school-children. Children of this sort 
seem languid and tired, they do not show the cheerfulness common to their 
age, are absent-minded, stare vacantly in school, and arouse as if from a dream 
when they are suddenly called. If these children have the unintelligent ex- 
pression described above, which is so common with adenoid proliferations, the 
parents, and particularly the teachers, regard them as weak-minded and an in- 
evitable encumbrance of the school, to whom attempts at instruction are use- 
less. Or, as is not infrequently the case, the teacher discovers that when the 
child is forced to momentarily concentrate his attention he is not so stupid 
and ignorant as would appear, which forces the conclusion that he is purpose- 
fully inattentive and indolent ; therefore punishment is instituted where treat- 
ment should be applied. How much this injustice reacts upon the child who 
realizes his shortcomings, how much family suffering, how many unsuitable 
occupations and miserable social positions are the outcome of these unrecog- 
nized consequences of adenoid proliferations is incalculable, and places in its 
full light the beneficent act of Meyer who has taught that all of these misfor- 
tunes might often be avoided by a slight operation. In the last few years 
school physicians and teachers have begun to devote some attention to these 
conditions and interesting statistics have been published. Thus, in 62 back- 
ward students Permewan found about 45 per cent., in 52 who were moderately 
intelligent about 30 per cent., and in 89 bright pupils about 21 per cent, with 
adenoid vegetations. Felix found among 1,038 bright and moderately bright 



494 DISEASES OF THE NASOPHARYNX 

students of the middle classes 28.52 per cent., and in backward pupils about 
35.10 per cent, with adenoid proliferations (quoted from Kotelmann). 

When we consider the multifarious and serious symptoms of disease which 
may be definitely referred to proliferations of the pharyngeal tonsil it is not 
surprising that adenoids are held responsible for a number of other affections 
of infancy and have become a general source of disease in pediatrics. 

From the loss of appetite, the vomiting, and the deficient bodily develop* 
ment of such children an explanation of this kind is comprehensible and justi- 
fied, as every chronic pathologic process in the nose, pharynx, and ear is liable 
to interfere with the intake of food. 

Disturbances of sleep may also find their explanation in adenoid prolifera- 
tions. The hindrance of free respiration causes a frequent awakening, and in 
the morning the child arises pale and tired. In this sense Key's hypothesis that 
night-terrors often depend upon carbonic acid intoxication resulting from the 
exclusion of air by adenoids is plausible, and in severe cases justifies the 
removal of nasopharyngeal proliferations. 

More doubtful is the connection of adenoid vegetations with enuresis noc- 
turna, notwithstanding the fact that many authorities maintain such a relation 
(Ziem, Schmaltz, Korner, Gronbech, and others). The assumed pathologic 
process is somewhat artificial and on account of the great psychical influence 
upon the affection the result of adenotomy is by no means decisive. 

A relation of adenoid proliferations to asthma is favored, among others, 
by Hack and Chiari, to salivation by Conctoux, Haug and Eey ; the possibility 
of a secondary meningitis is maintained by Hopmann and Both, and an asso- 
ciation with ocular symptoms (conjunctivitis) by Snellen and Guye. Attempts 
to cure chorea, epilepsy, and every possible form of idiocy by way of the nose 
are extremes readily calculated to reduce the great importance of adenoid nasal 
proliferations in the pathology of infancy and must be depreciated by physi- 
cians and patients. 

A few remarks must be devoted to the relation of adenoid vegetations to 
scrofula and tuberculosis. 

Meyer has considered the question of the scrofulous foundation of adenoid 
vegetations but is not very enthusiastic concerning a relationship. Some 
authors have maintained such a connection (Trautmann, Bresgen, Semon, etc.) 
but have met with great opposition from others (B. Fraenkel, v. Lange, Haug, 
Ziem). At this time the majority of pediatrists incline to the latter view; the 
experience of private practice in particular shows that the " scrofulous habi- 
tus " is rarely associated with adenoid proliferations, and that even in those 
cases in which suppuration of the nose and enlargement of the glands may per- 
haps, by a liberal diagnostic standard, be referred to a " beginning scrofula " 
such symptoms disappear after removal of the adenoids. By a mindfulness of 
these facts we may add to our exact knowledge of the symptoms and sequels of 
retronasal proliferations a valuable aid in disintegrating the by no means 
secure structure of scrofula. It would be in the interest of pediatric lucidity 
if the collective conception of scrofula were to disappear, resolving itself into 



ADENOID VEGETATIONS IN THE NASOPHARYNX 495 

its essential parts. Besides tuberculosis, syphilis, pediculosis, etc., adenoid pro- 
liferations in the nasopharyngeal space occupy a not small portion of the realm 
of scrofula. This, however, does not deny that changes in the mucous mem- 
brane due to adenoid growths may continue to exist after removal of the pro- 
liferation, and that then, as we have demanded for scrofula, a predisposition 
arises in the body and not an external cause for the continuance of diseases 
limited to the regions of the mucous membrane and lymph glands. In this 
sense adenoid proliferations might be the starting-point of scrofulosis. 

Tuberculosis also may find its port of entrance in adenoid vegetations. 
This view is favored not only by clinical experience, the interpretation of which 
may, however, be at fault, but by the anatomical findings, in that tuberculous 
nodules — i. e., caseation — have not infrequently been discovered in the extir- 
pated pharyngeal tonsil (Brindel, Gottstein. Pluder-Fischer. Rethi. and 
others). To conclude from this that adenoid vegetations are the sequel of 
tuberculosis, or, for those who identify tuberculosis with scrofula, are due to 
the scrofulous constitution, would not be correct. It is much more reasonable 
to assume that tubercle bacilli which have entered with the inspired air are 
retained by the adenoid structures of the upper air passages and lead to local 
disease. This would be a new indication for the extirpation of vegetations, 
coinciding with the removal of a primary tuberculous focus. 

Diagnosis. — The rich symptomatology furnishes enough supportive data to 
imply a diagnosis of adenoid vegetations from the clinical facts. For a posi- 
tive diagnosis, however, a local examination is necessary, for which three 
methods are available: Anterior rhinoscopy, posterior rhinoscopy, and digital 
examination. Mere inspection of the pharynx will not reveal the lower walls of 
the proliferation except with very large tumors; much experience is required 
to determine whether the soft palate is forced forward, as is sometimes the case 
with extensive adenoids. 

In regard to anterior rhinoscopy with the nasal speculum Chiari asserts: 
" After removal of the mucus, in a nasal passage that is at all dilated an eleva- 
tion of the velum will be observed when the patient pronounces the letter e. 
It will be seen that the velum moves to the lower border of a light red swelling 
in the nasopharyngeal space ; this mass has a straight or wavy margin and is 
itself raised by the velum so that the light reflex originating from its anterior 
surface distinctly shows the displacement. 7 '' Although this mode of investiga- 
tion is advantageous on account of its facility and the avoidance of pain, it is 
of little use in children's practice. On the one hand, expertness is necessary 
in recognizing the findings, which may not be familiar to every pediatrist, and 
on the other hand the nearness of the reflector frightens the child so that a 
quiet examination is difficult. This is all the more true of posterior rhinoscopy, 
the management of which requires great skill on the part of the physician as 
well as a certain amount of intelligence in the patient. The latter method, 
however, undoubtedly furnishes reliable results and permits the recognition 
of the adenoids, as swellings or growths, which are supplied for the most part 
with furrows and indentations. 



496 DISEASES OF THE NASOPHARYNX 

In children's practice these methods can only be utilized in exceptional 
cases and in the hands of expert laryngologists. The most positive means of 
recognition of the adenoids and a method that is easily accomplished is digital 
examination. 

For this it is necessary to extend an index finger to the height of the choana, 
behind the velum, with the head of the child inclined forward. The investiga- 
tor first opens the mouth with a tongue depressor. The index finger (usually 
the right) is then inserted to the posterior wall of the pharynx, the tongue de- 
pressor is withdrawn, and the bent middle and terminal phalanges of the finger 
are next extended into the nasopharyngeal cavity. In this examination it is 
well for the physician to stand alongside the child, who is seated upon a low 
chair, so that he can steady the head with his free left arm ; this is absolutely 
necessary when assistance is not at hand and the physician himself must fix the 
head of the child. The danger of biting is extremely slight when once the 
finger has reached the posterior pharyngeal wall; as a matter of precaution, 
however, the cheek may be depressed between the teeth by an assistant during 
the examination. This investigation must be very rapid on account of the 
decided gagging and resistant movements of the child and its fear of suffoca- 
tion. The entire art of diagnosis with the palpating finger lies in the fact that 
in a few seconds a clear estimate of the condition may be obtained. The be- 
ginner often fails by allowing too much time for the child to offer resistance 
and by not forcing his finger high enough, so that the upper pole of the tonsil 
which narrows the passage is mistaken for adenoid proliferations of the naso- 
pharynx. Lesions of the mucous membrane and slight hemorrhage are fre- 
quently produced during this examination but rapidly subside without treat- 
ment. 

Another form of diagnostic exploration is occasionally advised. In doubt- 
ful cases, instead of the finger, a bent forceps is introduced from the mouth 
into the nasopharyngeal space and an attempt made to grasp any obstruc- 
tion to its entrance. If lymphatic tissue is withdrawn adenoid proliferations 
are present; if not, they are absent. This procedure is not justifiable, as 
it eliminates the indications for operation, which for ethical reasons must 
be sharply defined, even in a relatively simple and beneficent surgical 
procedure. 

If we are convinced by digital examination of the presence and consistence 
of adenoid masses in the nasopharynx, the diagnosis is positive. Only excep- 
tionally are other tumors present in the nasopharynx, as fibroid nasal polyps, 
which are much coarser, or soft sarcomata, which bleed readily, or gummata, 
all of which must be considered in a differentio-diagnostic respect. Apart 
from the history and other signs of the disease, if the local condition is not 
sufficiently defined only a histologic examination of an extirpated particle and 
the further course will be decisive. Another important question is whether the 
mass in the nasopharyngeal space is the only source of the trouble; therefore 
the possibility of hypertrophy of the tonsil or of enlargement of the turbinated 
bones must always be considered. 



ADENOID VEGETATIONS IN THE NASOPHARYNX 497 

Prognosis. — As regards life the prognosis is always favorable; only when 
severe complications (otitis, tonsillitis, meningitis, pneumonia, etc.) arise does 
it become serious. A spontaneous disappearance of the pharyngeal tonsil is 
very probable. Chiari states that the same conditions prevail with adenoids 
as with the palatine tonsil, which shows its greatest development between the 
fifth and eleventh years of life, and then gradually disappears. With the 
growth and enlargement of the nasopharynx the disturbances due to occlusion 
are sometimes overcome. The accompanying catarrhal condition declines grad- 
ually. We may then speak, in a clinical sense, of spontaneous recovery, even 
when the pharyngeal tonsil as such has not become smaller. Often enough, 
however, the symptoms of the disease continue even in adolescence, and we 
must then resort to operation. 

Treatment. — Adenoid proliferations in the nasopharynx offer a fruitful 
field for professional activity, and the treatment of the affection has been de- 
veloped in detail. 

The only correct method of treatment, if this be at all necessary, is the sur- 
gical removal of the proliferations. Only with children and parents who fear 
the knife and with direct contraindications to an operation may applications be 
employed. This method is accomplished either with a fine probe covered with 
cotton, which is passed through the nasal cavity or, better, with a bent probe by 
way of the mouth. A 5-10 per cent, solution of nitrate of silver is employed. 
Great success is not to be expected from this treatment ; at best, only the accom- 
panying catarrh is improved. Treatment of this kind, however, is rarely com- 
pleted; the patients object to the unpleasant method and declare to the physi- 
cian that the condition has decidedly improved. 

lYhen do adenoid vegetations in the nasopharynx require operation' 1 ? To 
this there can be only one answer : When they give rise to distinct, characteris- 
tic symptoms. The mere presence of an enlarged pharyngeal tonsil, without 
S}mrptoms of disease, is just as little an indication for operation as the existence 
of indefinite factors which do not belong to the clinical picture of adenoid vege- 
tations. It is true, experience shows that the indications for operation vary 
widely. In contrast with those physicians who are timid with the knife, who 
are only too readily influenced by the unnecessary fear of the parents, there are 
many others who regard every pharyngeal tonsil as the starting-point of com- 
plications and look upon a slight coryza as a signal for operation. If, in de- 
ciding upon operation, we are not guided by subjective impressions, which will 
not be undervalued by the experienced physician, but are governed by definite 
factors, then the relapsing otitis and a tendency to pseudo-croup or to febrile 
bronchitis in small children, and in older children difficulties in speech and 
aprosexia, are to be regarded as positive indications for operation. The fol- 
lowing are contraindications for surgical intervention : Hemophilia and other 
diseases of the blood, acute febrile conditions, tonsillitis, and the epidemic ap- 
pearance of diphtheria and scarlatina in the vicinity of the child. To these 
Abeles has added valvular disease and other affections which are accompanied 
by stasis in the course of the superior vena cava, epilepsy, severe hysteria, and 
33 



498 DISEASES OF THE NASOPHARYNX 

the presence of an intense ciliary injection of the eye. Neither infancy nor 
anemia are contraindications for operation. 

For the operation a cutting instrument is introduced, in the same manner 
as the finger in digital examination, to clear the nasopharynx of adenoid tissue. 
To accomplish this with the finger-nail, as is occasionally suggested, is not 
advisable in the present era of the greatest possible cleanliness. The cutting- 
ring, to be adjusted to the finger of the operator, which was at one time advised 
(Justi, Bezold, and others) is not practical for the reason that the crowding 
finger interferes with a thorough removal of the proliferations. At present the 
curette and forceps are employed and many rhinologists subsequently use a cold 
snare. 

The curettes which are in use are those of Gottstein, v. Lange, Hartmann, 
Gruber, Politzer and Fein, and others, all of which are composed of an egg- 
shaped, continuous ring with an inner cutting edge, arranged at a right angle 
upon a firm handle. The numerous modifications of the original Gottstein 
knife differ principally in the size and shape of the ring and its curvature, and 
in the position of the cutting surface. A very practical device is that of Fein, 
the handle of which is curved so that the field of operation is not obscured by 
the hand. 

The choana forceps for the removal of adenoid vegetations (Catti, Jurasz, 
Schiitz, etc.) has upward-curving branches, the ends of which terminate in a 
sharp spoon or edged rings. By this instrument the proliferations are cut and 
pinched off. At the present time these forceps are utilized for the removal of 
adhesions remaining after Gottstein' s method has been employed, rather than 
for the actual operation. 

The steel snare* (Blake, Chiari, etc.) is introduced either through the nose 
or by the oral cavity. Both methods of application have their adherents. 
Chiari favors the nasal employment of the snare, Stoerk and others the retro- 
nasal removal. While the results of the snare are satisfactory in the hands of 
an expert and with quiet patients who are cocainized, the method is difficult 
in children's practice on account of the necessity of repeated introduction of 
the instrument and because of the enrolment of large doses of cocain, which 
is especially necessary with operation through the nose. Some operators use 
the snare after Gottstein's knife has been employed, as by this means the vege- 
tations remaining in the pharyngeal vault are readily grasped and removed. 

A greatly discussed question is whether anesthesia is advisable for the remo- 
val of adenoid vegetations. Some laryngologists resort to it invariably to 
obviate the possibility of resistance from the child and to insure a quiet and 
thorough operation. Others object to the measure because the shock of narco- 
sis in children is usually very alarming, the expectoration of blood and parti- 
cles of tissue is prevented, and finally because the operation may be done rapidly 
and easily without anesthesia and thus eliminate the complications of narcosis. 
If anesthesia is employed at all it should not be so profound that the reflexes 
are abolished ; a mild etherization, such as is often employed in minor surgery, 
appears to be the most suitable for this purpose. 



ADENOID VEGETATIONS IN THE NASOPHARYNX 499 

The method of operation is as follows: The child is held by an assistant, 
with the feet encased between his knees and one arm surrounding the body and 
fixing the hands. Small children are swathed, mummy-like, in a sheet which 
is fastened with safety-pins. With the other arm the assistant holds the head of 
the child firmly toward him. Two people are often necessary for this purpose. 
The operator sits opposite the child, opens the mouth with a tongue depressor, 
introduces the instrument into the pharynx, and thence into the nasopharynx. 
If, as is usual, the Gottstein instrument is employed, strong scraping 
movements from left to right and from above downward are necessary, dur- 
ing which the experienced operator can determine whether he is still working 
upon soft tissue within the nasopharynx. When the instrument is withdrawn 
the head must be inclined forward so as to permit a free path for the profusely 
flowing blood. The adenoid tissue which has been scraped away may adhere 
to the knife or be expectorated with the blood, but very often the masses are 
swallowed and digested, sometimes vomited. The operation lasts a fractional 
part of a minute. The hemorrhage soon ceases, but before the patient is re- 
leased the operator should convince himself by inspection of the pharynx and 
digital examination that no shreds of the proliferation are hanging toward the 
pharynx and that the adenoids have been completely removed. Some rhinolo- 
gists always introduce the cold snare into the nasopharynx after the operation, 
either by way of the nose or the pharynx, to remove remaining particles from 
the roof of the nose. Loose shreds may readily be removed by the Jurasz for- 
ceps, which is sometimes preferred for the operation. After the operation is 
completed the patient should remain under the eyes of the operator from thirty 
minutes to an hour, or until the hemorrhage has entirely ceased. 

The after-treatment is exceedingly simple. If local measures are necessary 
daily insufflations of dermatol, sodium sozoiodol, etc., through the nose may be 
emploj^ed. Small children should be kept in bed for a day or two and older 
ones for at least four or five days in a room in which there is plenty of ven- 
tilation but no dust. The food in the first days is to be fluid or soft. Ice-cream 
after the operation is often soothing and quickly relieves the unpleasant sensa- 
tions. The process of healing is smooth and uninterrupted; only in rare cases 
are there local inflammatory phenomena, described above. 

Relapses/ that is, the necessity for subsequent operation, may be noted even 
when the primary operation was thoroughly done. This is particularly true of 
the operations upon infants — a circumstance which should be considered with 
the indications for operation at that period of life. Three per cent, of relapses, 
estimated by N. Schmidt, is probably too low, as patients often seek a different 
nose specialist for relapses. Of greater value would be the reports of family 

1 Many " relapses " in the shape of adenoids or of chronic catarrh after the opera- 
tion result from the fact that the operators, mainly those who specialize, are sat- 
isfied with the " operation." A chronic nasal catarrh, a sore surface left behind after 
the scraping with Gottstein, and the tendency to adenoids, require two daily warm 
saline irrigations of the nares. This simple manipulation renders many an operation 
superfluous. — Editor. 



500 DISEASES OF THE PHARYNX 

physicians, who are in a better position to know whether symptoms of nasal 
stenosis reappear after removal of the proliferations. 

The result in by far the majority of cases is convincing and permanent. 
Improvement in speech, the possibility of blowing the nose, the pleasant sensa- 
tion of free nasal respiration, quiet sleep without snoring and with closed 
mouth, are sequels which may often be recognized within the first twenty-four 
hours after the operation. No fear need be aroused if, two or three days later, 
there is an apparent aggravation, brought about by a reactive swelling of the 
surface of the wound. This soon disappears, giving place to permanent health. 
The rapid mental and bodily development of a child who had previously suf- 
fered from the depressing symptoms of adenoid proliferation is often surpris- 
ing. 

DISEASES OF THE PHAEYNX 

Diseases of the pharynx in childhood do not come within the scope of this 
article as they do not differ from similar conditions in adults and have been 
described at another place in connection with tonsillitis. 1 

In children acute catarrhal pharyngitis occurs as a substantive disease or in 
association with inflammation of the palatine arches, the tonsils, the nose, and 
the nasopharynx; chronic inflammations of the mucous membrane of the pha- 
rynx are observed principally in diseases of the nose and in adenoid vegetations. 
Not rarely do we meet with typical forms of pharyngitis granulosa, and phleg- 
monous varieties are found which are mostly associated with a corresponding 
disease of the tonsils and the palatine arches. Finally, the various pharyngeal 
affections appearing in the infectious diseases, particularly in diphtheria, 
measles, and scarlatina, must be mentioned which, as a rule, are very charac- 
teristic and of decided diagnostic importance. 

All of these conditions are common in children's practice, certain of them 
being more frequent than in adults, such as inflammation of the tonsils and the 
pharyngeal affections in infectious diseases, and in infancy particularly they 
are often succeeded by lymph-gland enlargement and disease of the ear. For 
the pediatrist there is an especially important relation between relapsing tonsi- 
litis and acute endocarditis, and between articular rheumatism and chorea. 

A more comprehensive description will be devoted to a form of disease 
which is peculiar to children, and has not been given the importance it de- 
serves, namely 

ACUTE LYMPHADENITIS RETROPHARYNGEAL^ 

By lymphadenitis retropharyngeal we understand an acute febrile en- 
largement of those lymph nodules which are situated upon both sides of the 
median line of the posterior pharyngeal wall. Bokai, senior, in his pioneer re- 
port upon retropharyngeal abscess (1857) called attention to the non-suppura- 

1 See volume on " Infectious Diseases." 



ACUTE LYMPHADENITIS RETROPHARYNGEAL^ 501 

tive inflammation of these lymph-glands, which he sharply separated from 
acute pharyngitis, but the interest of physicians has been more especially de- 
voted to the suppurative varieties of this glandular inflammation and the know- 
ledge of simple lymphadenitis, notwithstanding Baginsky, Neumann, and 
others, is very slight. 

The affection usually begins with the symptoms of an acute pharyngeal in- 
flammation, from which, under peculiar bacterial conditions, it probably always 
originates. The fever is not extreme— between 38° and 39° C. (100.4°-102.3° 
F.) — sometimes intermittent in character, perhaps with remissions of several 
days. The constitutional condition of the child, however, is as a rule decidedly 
changed. At first there is difficulty in deglutition and headache. The tongue 
is heavily coated and the appetite lost. With small children proffered fluids 
may be quickly grasped but after a few attempts to swallow the food is resent- 
fully rejected. Inspection of the throat reveals redness of the pharynx ; exami- 
nation with the finger at first shows merely a loosening, unevenness, and swell- 
ing of the pharyngeal mucous membrane, which readily bleeds upon irritation 
with the finger-nail. After one or two days, and often from the onset of the 
disease, the palpating finger discovers, laterally from the median line, a soft, 
elastic, non-fluctuating, elongated, apparently painful enlargement on the pos- 
terior wall of the pharynx, at the height of the palate or usually somewhat 
deeper. This enlargement corresponds to a pharyngeal lymph-gland, with 
which we have become familiar through the investigations of Most. There- 
fore, we are apparently concerned with an inflammation of the profuse net of 
lymphatics situated upon the posterior wall of the pharynx, with consecutive 
swelling of the adjacent pharyngeal lymph-nodules. In this stage of the dis- 
ease another symptom arises which is much more prominent than the trans- 
formation in the interior of the pharynx and to unobservant parents is some- 
times the first indication of the trouble. This is a moderate enlargement of 
the lymphatic glands at the angle of the jaw, that is, on the anterior border or 
under the insertion of the sternocleidomastoid, belonging to the group of deep 
cervical glands. 

This lymph-gland enlargement is a troublesome as well as conspicuous 
symptom. In the course of a few days, and sometimes within a few hours, 
these glands (one or two upon each side) enlarge to the size of a nut or even 
a small apple, causing a decided deformity. Sometimes the swelling is only 
unilateral, but as a rule it is unequally distributed to both sides. 

The greater enlargement corresponds with the side of the lymph-gland in- 
flammation in the pharynx. The localization of the tumor under the mastoid 
process, the commonly severe pain upon pressure, the doughy infiltration of the 
surrounding area, which at first makes a sharp limitation of the gland impos- 
sible, closely resemble mumps, for which the affection is often mistaken. A 
slanting position of the head and decided resistance of that member to passive 
movement are the ordinary consequences of this painful glandular enlargement. 

The swollen region at first is usually of a soft, elastic consistence, appar- 
ently due to edema of the parts surrounding the gland. When the edema dis- 



502 DISEASES OF THE PHARYNX 

appears the gland is recognized as a hard, coarse tumor. Fluctuation and sup- 
puration are rare. 

The disease may remain in this stage for eight to fourteen days. The rest- 
lessness of the child, caused by the great swelling of the external lymph glands, 
the inadequate nourishment in consequence of inflammation of the retropharyn- 
geal gland, the fever, the constant disturbance of sleep, stamp the condition as 
serious, but rarely is it dangerous, although the patient is considerably ema- 
ciated. After watching this condition for several days the physician will often 
conclude to incise the tumor in the posterior pharyngeal wall with the expecta- 
tion of finding a suppurative focus, not perceptible by palpation, 'or for the 
purpose of relieving tension. Upon decline of the fever recovery ensues, but 
the glands under the insertion of the sternocleidomastoid usually remain en- 
larged for some time. In other cases a gradual abscess formation results from 
this retropharyngeal adenitis which exhibits the typical symptoms of retro- 
pharyngeal abscess and heals rapidly after incision. 

In one of my cases fourteen days elapsed before the lymphadenitis pro- 
ceeded to suppurate. 

The above-described course of acute retropharyngeal adenitis was observed 
by me in 6 cases, the ages of the patients ranging from nine months to five 
and a half years. Two of these children were related and were affected in 
rapid succession, not by direct contact but through a third person who suffered 
from a mild tonsillitis. A clearly epidemic occurrence of the malady has been 
reported several times (Bokai, etc.). 

Prognosis. — The prognosis of simple acute retropharyngeal lymph-adenitis 
is good, although the process of healing is sometimes greatly protracted and the 
child is much emaciated. In small children the difficulty in taking nourish- 
ment and the fever may make the condition menacing. There is also a possi- 
bility of mechanical hindrance of respiration and of edema of the glottis ; the 
danger is then as great as in retropharyngeal abscess — perhaps more so, because 
the relief of the condition is not so simple. These symptoms, however, are more 
rare in acute lymphadenitis than in abscess. 

Treatment. — The treatment is purely symptomatic and consists of vapor 
packs with water or dilute aluminum acetate, the external application of iodin 
or ichthyol in salve or vasogen, together with gargles, applications to the pha- 
rynx, etc. 

RETROPHARYNGEAL ABSCESS 

In intimate relation with these enlargements of the lymphatic glands is 
retropharyngeal abscess. Even in his early report of this disease Bokai, senior, 
sharply differentiated it from the varieties of acute pharyngitis, declaring it to 
be a suppurative inflammation of the glands behind the pharynx. The ana- 
tomical basis of this clinical observation was proven later by Most and others 
who demonstrated the presence of lymph glands in the posterior pharyngeal 
wall. 

Since the first publication regarding retropharyngeal abscess by Bokai, 



RETROPHARYNGEAL ABSCESS 503 

senior (1857), cases have been reported by a number of other authors (Alexy, 
Henoch, Schmitz, Bokai, junior, Temoin, Oppenheimer, Dollinger, Neumann, 
Koplik, Sokoloff, Burckhardt, and others) and at the present time we possess 
a very comprehensive knowledge of the disease. 

Symptoms. — In contrast to non-suppurative lymphadenitis retropharyngeal 
abscess principally occurs in the first year of life. Henoch classes the affection 
in his text-book among the diseases of nurslings. The prodromal symptoms 
and the fever are not severe and the local phenomena are usually the first 
noticeable indications of the affection. These consist of rejection of food, 
swelling of the glands, snoring, increasing difficulty in respiration. After a 
few attempts at the breast or bottle the child unwillingly lets go as deglutition 
causes pain and also inhibits respiration. In the words of the mother, breast- 
children are weaned of their own accord. The enlargement of the glands under 
the insertion of the sternocleidomastoid is usually not so great as in the non- 
suppurative lymphadenitis of the posterior pharyngeal wall, although it is 
rarely absent. Instead of the distressing unilateral position of the head there 
is often a forward inclination which is due not merely to the enlarged lymph- 
glands in the neck but also to the restriction of respiration by the abscess. 

The latter is the most important and serious symptom of the disease. 

The respiration at first has a peculiar snoring quality which is often as- 
sumed to result from coryza and is especially pronounced during sleep. This 
hindrance of respiration gradually becomes more prominent, the child sleeps 
poorly, awakens readily, and, as Henoch expresses it, gasps for air. A condi- 
tion may now arise which is as distressing for the parents as it is serious for 
the child. Breathing even with the aid of the auxiliary muscles is difficult, the 
child is cyanotic, inclines the head forward, and energetically refuses food, as 
even a brief closure of the mouth during feeding gives rise to suffocation; 
briefly, there is the well-defined picture of respiratory stenosis which is only too 
often encountered in diphtheria. Even at this stage, unfortunately, the malady 
is often unrecognized and is mistaken for laryngeal croup. Bokai tells of a 
surgeon who was called in haste to perform a tracheotomy in a supposed case 
of diphtheria but was unable to save the child, who was in the agonal stage, 
by an immediate incision of a retropharyngeal abscess which he found instead 
of diphtheria. I also know of a child who, the day after I had incised an idio- 
pathic retropharyngeal abscess, was admitted to a hospital for diphtheria, 
probably because the wound of the incision was coated and the still-existing 
dyspnea, in the absence of a clear history, resembled laryngeal diphtheria. In 
these cases, aside from the history, only the cough can be considered as proof, 
which lacks the barking, hoarse character of the laryngeal affection. Henoch, 
however, reports cases in which the nature of the cough was uncertain on ac- 
count of a secondary laryngeal catarrh which rendered a correct diagnosis 
exceedingly difficult. Such examples make it evident that in all cases where 
the history is unknown a digital examination of the pharynx is necessary; in 
addition to retropharyngeal abscess the possibility of a foreign body requires 
this measure. 



504 DISEASES OF THE PHARYNX 

Digital examination in retropharyngeal abscess reveals a condition which is 
unmistakable. The posterior pharyngeal wall is felt to bulge markedly and a 
fluctuating tumor the size of a hazelnut or chestnut is readily palpable. This, 
like the non-suppurative adenitis, is situated laterally from the median line, 
but with a fully developed abscess which completely fills the palpable posterior 
pharyngeal wall its position is not easily defined and a day often elapses after 
the pus has been discharged before it is possible to determine from which side 
the abscess originated. 

When the physician has decided that a retropharyngeal pus cavity is present 
incision should not be delayed. This operation is a vital necessity, for with 
delay either a serious asphyxia, previously described, may arise or spontaneous 
rupture of the abscess may permit pus to escape into the respiratory passages 
causing, sudden death or a secondary deglutition pneumonia. Henoch reports 
an instance of this kind: A physician who wished to demonstrate a case of 
retropharyngeal abscess upon the following day lost his patient during the 
night by an attack of suffocation. Even an incision made at the proper time 
is not without danger. During and after the operation pus may find its way to 
the respiratory passages, giving rise to dyspnea and later a deglutition pneu- 
monia (Temoin). I myself remember a case in the clinic in which I opened 
an abscess without any special difficulty and after cleansing the wound and 
arresting the flow of blood sent the child home. About an hour later the 
mother returned with the report that the child had died suddenly on the way 
home. 

The internal incision should never be undertaken without sufficient assist- 
ance. One person holds the child, closely enveloped in a sheet as for an intu- 
bation, while another fixes the head firmly and, immediately upon the signal of 
the operator, inclines the head forward so as to facilitate the flow of pus 
through the mouth. There has been much discussion concerning the instru- 
ment with which the incision should be made. Some authors utilize the finger- 
nail, but this does not fulfill the modern requirements of cleanliness and the 
insufficient opening is very liable to close. Usually a pointed bistury is em- 
ployed, the cutting edge being covered by adhesive plaster. Some authors have 
invented special instruments for this and similar operations but they are em- 
ployed chiefly by specialists. 

In my experience the best results have been obtained by a simple drainage 
forceps/ which may be sharpened at the end if desired. The advantages of 
the instrument, which is employed also by Huber, are that it has no cutting 

1 The " simple drainage forceps " recommended by the author and Dr. Francis 
Huber, that distinguished all around doctor and teacher, may refuse now and then 
when the soft parts outside the abscess do not give way to a blunt instrument like 
a forceps. Then a strong probe, sharpened or not, or a director will pierce the parts, 
and may be utilized to enlarge the wound, mostly downwards. 

The lateral operation, from outside, is not so dangerous as the author seems to 
suggest. No neighboring blood-vessels need be feared, for the incision is made outside 
and behind the cleidomastoid muscle, and the operation can be finished with blunt 
instruments. — Editor, 



RETROPHARYNGEAL ABSCESS 505 

edge and therefore does not produce secondary injury, that after insertion into 
the pus focus the arms of the forceps may be opened to any desired extent, that 
every physician possesses the instrument, and that it is readily cleaned and is 
not spoiled by the operation. 

Evacuation of the abscess does not complete the duty of the operator. In 
addition it is necessary to note that the pus has been completely discharged 
and that the bleeding has ceased. To determine the former the cavity may be 
gently stroked from below upward. When the discharge of pus is profuse the 
child should not be permitted to go home on account of the danger mentioned 
above. Washing of the field of operation through the nose or pharynx is not 
advisable as the dyspneic child is already much frightened and distressed and 
on account of the impossibility of expectoration there may be cough and per- 
haps aspiration of some of the cleansing fluid. Removal of the pus from the 
mouth will usually prove sufficient. As a rule the hemorrhage is not profuse, 
but if necessary compression may be practised with pellets of cotton. The 
abscess must be inspected again upon the following day and if it has refilled the 
operation must be repeated. 

The dangers of pharyngeal evacuation of the pus have led to other opera- 
tive proposals. Thus, it has been suggested to operate with the head hanging — 
a method which has proved of service in many operations upon the pharynx 
and mouth. This will not be the preferred operation in a very dyspneic child 
and also requires an additional assistant and a greater amount of skill than in 
the simple opening of the patient's mouth. Neither is the procedure without 
danger, as is shown by a case reported by Zadock. Another method, strongly 
advocated by Burckhardt, is the external opening of the abscess, especially 
when it begins to protrude. Undoubtedly this is the correct chirurgical treat- 
ment as it permits of antisepsis, which is impossible with the internal method. 
This operation can be performed only in a well-appointed surgical dispensary 
and is not devoid of danger on account of the vicinity of the great vessels and 
nerves. A general employment of this measure, therefore, would result in 
fewer operations for retropharyngeal abscess and would not accrue to the ad- 
vantage of the patients. The rejection of this method by Bokai, junior, which 
is based chiefly upon the good results obtained in the Children's Hospital at 
Budapest by the pharyngeal operation is therefore justified. 

That the result of the operation, in an overwhelming majority of the cases, 
is brilliant has already been stated, and few operations as simple have met with 
such great success. Bokai, junior, reports that among 138 cases operated upon 
under his direction 106 were subjected to the internal method, of which only 
three fatalities among the dispensary patients could be considered as due to the 
operation. It is true there are cases with and without operation in which the 
pus takes an abnormal course and gives rise to serious complications. Henoch 
reports a few instances in which external rupture occurred behind the pharynx 
and into the ear. Inversely, particularly in scarlatina, a phlegmonous inflam- 
mation of the connective tissue of the throat may rupture into the pharynx and 
lead to discharge of pus through the fauces. 



506 DISEASES OF THE PHARYNX 

From these casuistic considerations it will be observed that if idiopathic 
retropharyngeal abscess is recognized and treated early its course is usually 
without danger, but if neglected it may become an exceedingly serious malady. 

The correct diagnosis and the proper treatment should become the common 
property of all physicians, just as is the performance of a life-saving trach- 
eotomy. In any throat affection that is at all obscure a digital examination of 
the pharynx at least should be required as the failure to recognize this affec- 
tion would then be almost impossible. 

Etiology. — Thus far in our discussion of " idiopathic " retropharyngeal 
abscess we have not considered its etiology or its relation to other diseases. 
Regarding these questions there is some uncertainty. 

The existence of a constitutional basis (scrofula, tuberculosis), or at least 
of a chronic local affection of the mucous membrane of the pharynx and nose, 
is assumed by some authors (Bokai, Baginsky, Walls), and denied by others 
(Schmitz, Henoch, Stoos). Dollinger's case, upon which an autopsy was held, 
occurred in a tuberculous individual but without any evidence of tuberculosis 
in the abscess itself. For the professional conception of retropharyngeal abscess 
it is sufficient to know that the malady is observed in children who neither 
were nor have become scrofulous or tuberculous. This, however, does not ex- 
clude the possibility of a predisposed condition of the mucous membrane. 

Bacteriologic investigations regarding idiopathic retropharyngeal abscess 
have been reported by Koplik; in all cases this author found streptococci. 

Eetropharyngeal suppuration is sometimes associated with influenza 
(Fischer, Stoos). So long as this connection depends merely upon clinical 
evidence, not upon bacteriologic findings, the association must be regarded as 
doubtful. In the discussion of Pfeiffer's glandular fever it was remarked how 
often obscure febrile conditions in children sail under the false colors of in- 
fluenza. 

In scarlatina retropharyngeal abscess is not rare. It is then a secondary 
condition of the phlegmonous pharyngeal process which may result in a col- 
lection of pus over the entire posterior pharyngeal wall. Cases of this kind 
are exceedingly severe and even incision of the abscess does not often give re- 
lief ; sometimes an aggravation of the local condition is produced by necrotic 
destruction of the walls of the abscess. 

Spondylitic gravitation abscess must also be mentioned. This occasionally 
forms upon the posterior wall of the pharynx, simulating a retropharyngeal 
abscess. A differential diagnosis of these from idiopathic retropharyngeal 
abscesses is considered theoretically more often than in practice; only excep- 
tionally will the spondylitis fail to produce symptoms and the disturbances of 
the retropharyngeal tumor alone call attention to the gravitation abscess in 
this locality. However, in this secondary phenomenon of cervical spondylitis 
we are no longer concerned with a retropharyngeal abscess, in the strict sense 
of the term, but with a suppuration appearing upon the posterior pharyngeal 
wall which has originated at some remote point. 

In conclusion, the possibility of a traumatic origin of retropharyngeal ab- 



RETROPHARYNGEAL ABSCESS 507 

scess must be mentioned. Such a condition is favored if a hard substance has 
been swallowed or has lodged in the throat, producing a lesion of the pharyn- 
geal wall and a secondary suppuration. Substances accidentally introduced 
into the mouth may give rise to the same consequences (particles of glass, 
splinters of wood, etc. ) . 

From these considerations it is evident that in addition to the " idiopathic " 
retropharyngeal abscess of infancy the condition may arise secondarily in 
various diseases. In none of these cases is it possible to exclude streptococcus 
infection as the basis of the trouble, as is shown by the investigations of Kop- 
lik and the repeated experiences in scarlatina. 

The knowledge of adenoid vegetations and of retropharyngeal abscess are 
acquirements of the last decades. We must be grateful to W. Meyer and Bokai, 
senior, for their explorations which have opened new paths for pediatric inves- 
tigation as well as for the beneficial activity which they have furnished to the 
physician. 



MENINGITIS OF INFANCY, AND 
HYDROCEPHALUS 

By O. Kohts, Strasburg 

SIMPLE MENINGITIS 

The brain is enveloped by membranes, the dura mater, the arachnoid, and 
the pia mater. The dura mater covers the brain at predominant areas and par- 
ticularly at the base, is firmly adherent to the bone, sends ramifications into 
the foramen cranii, and is continuous with the periosteum. In children this 
membrane is less adherent to the skull than in adults. The meningeal vessels 
are found in these fibrous integuments. The dura mater is comprised of an 
external and an internal layer. The inner layer sends branches to the various 
cavities of the brain. 

The arachnoid also has two layers, one lying close to the inner surface of 
the dura mater and covered with a single epithelial layer, while the visceral 
surface comes in contact with the pia only at the prominent portions of the 
cerebral convolutions. Both layers unite at the nerve roots and sometimes 
accompany them for quite a distance. Between the layers there is but little 
serum. A narrow space between the pia mater and arachnoid contains the cere- 
brospinal fluid. 

The pia mater is a very delicate tissue, rich in cells, which lies directly over 
the brain. It surrounds the cerebral convolutions and fossae, permeates deeply, 
and forms the choroid plexus of the lateral and middle ventricles. Its inner 
layer is continuous with the greater number of vessels and also forms the 
sheath for each nerve. It is uncommonly luxuriant in blood and in nerve 
fibers. 

The cerebral membranes continue to the spinal cord. The arachnoid is 
never alone implicated by inflammation, but is inseparably involved in inflam- 
mation of the dura (pachymeningitis) or of the pia (leptomeningitis) . 

The term " meningitis " designates an inflammation of the pia mater and 
of the visceral layer of the arachnoid. This inflammation arises from widely 
diverse causes of infection, and since the most varied pathogenic agents may 
produce the same clinical picture we are usually unable at the onset to form 
any conclusions regarding the nature of the infection. Exceptions to this are 
furnished by tuberculous meningitis and epidemic cerebrospinal meningitis, 
which in many cases present somewhat characteristic clinical phenomena. 

Meningitic symptoms accompanied by fever are also noted in the course of 

508 



SIMPLE MENINGITIS 509 

the most varied diseases, as pneumonia, enteric fever, influenza, dysentery and 
otitis media, as the result of intoxications, or as reflex phenomena. 

The complete clinical picture of meningitis may be observed without the 
demonstration post mortem of any changes of the meninges. In the absence 
of manifest changes in the brain and of microorganisms in the cerebrospinal 
fluid and in the blood, the symptoms must be referred to toxins which produce 
vascular dilatation and cerebral circulatory disturbances. 

A neuropathic predisposition, extraordinary mental development, the 
greater sensitiveness of the brain of children, are given as reasons for the 
more frequent occurrence of cerebral symptoms — the symptoms of meningitis 
— in youth. Exceptionally the signs of chronic meningitis are found at the 
autopsy, whereas during life there were no symptoms corresponding to that 
affection. Simple meningitis was first differentiated from tuberculous menin- 
gitis by Hopfengartner (1802) and by Eilliet. The earliest investigations 
appertaining to the relation of meningitis and micrococci were made by Klebs. 
This author demonstrated post mortem the existence of diplococci in the 
exudate of an individual who had succumbed to the disease. Later Eberth and 
v. Leyden isolated cocci and diplococci, and finally Netter, Fraenkel, Saenger, 
Weichselbaum, Foa, Bordoni, Uffreduzzi, Jaccoud, Hutinel, Schafer, and oth- 
ers, established the presence of the various micrococci which play a role in the 
non-tuberculous forms of meningitis. 

Acute meningitis is more common in adults than in children. On the 
other hand, children are the more frequent victims of the tuberculous form. 
The disease usually attacks well-nourished individuals and is especially preva- 
lent in the first two years of life and after the sixth or seventh year. Quite 
exceptionally it has been observed in the newborn (Billard and Guersant). 

Micrococcus infection may be the result of a trauma or .of the transmission 
of inflammation from the surroundings through the lymph channels, or by 
metastasis through the circulation. An especially predisposing factor of men- 
ingitis is furnished by inflammation of the nasal and orbital cavities, of the 
frontal sinus, and of the ears. Direct effect of the sun, injury of the skull, 
or even lesions of the cutaneous covering of the skull, may occasion menin- 
gitis, or it may originate from fractures or septic diseases of the cranium, 
osteomyelitis or septic conditions emanating from disease of the face and the 
skin, furunculosis, impetigo, anthrax, phlegmons, and extensive burns. Acute 
meningitis may occur either in the course or as the sequel of disease of the nose 
(coryza, ozena, tuberculosis, syphilis), or of the ear (suppurative otitis). 

Secondary meningitis, due to pneumonia, is more commonly associated with 
other diseases, such as septic pleurisy, pericarditis, endocarditis, etc. 

Eefrigeration, wetting, a preceding trauma, hereditary predisposition, pre- 
mature mental development, and alcoholism of the parents appear to have a 
particularly favorable or decisive influence on the development of the affection. 

Acute meningitis is of a general or local nature. Predominating upon the 
convexity, it may also implicate the base of the brain or be present in the latter 
region exclusively. Here there may be a simple hyperemia of the arterial and 



510 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

venous vessels of the dura mater and of the pia, or an exudate develops which 
is serous, sero-fibrinous, or purulent. Quincke has described a purely serous 
exudate, generally occurring in earliest childhood, which develops with men- 
ingitic symptoms and sometimes terminates in recovery after repeated lumbar 
puncture. Under such circumstances there is more or less decided effusion 
into the cerebral cavities, lateral ventricles, and even into the third and fourth 
ventricles. The chambers of the brain are greatly dilated and filled with a 
transparent serous fluid, which is attributed to a simple serous exudation or an 
abnormal secretion of the choroid plexus. Quincke believes that vasomotor 
influences are responsible for the abnormal effusion, which afterward causes 
an increase of the intracranial pressure upon which the clinical symptoms are 
dependent. 

SEROUS MENINGITIS 

In serous meningitis the pia is decidedly reddened and edematous at the 
base of the brain and upon the convexity, and somewhat cloudy in the neigh- 
borhood of the vessels. This cloudiness is not due to leukocytic infiltration, but 
to a proliferation of the fixed elements. The cortex is usually anemic, the 
gyri are wide apart, and the sulci have disappeared. This form of meningitis is 
attributed to cold, mental overexertion, trauma, syphilis, and infectious dis- 
eases. Quincke asserts that in most cases there is no infection; other authors 
mention various microorganisms as causal factors in the pathogenesis of serous 
meningitis, such as pneumococci, streptococci, bacteria coli, typhoid and influ- 
enza bacilli, or their toxins. 

In simple meningitis the entire surface of the brain, in particular the con- 
vexity, is covered with purulent material. The exudate is commonly sero- 
purulent or purulent and as a rule occupies the arachnoid space. Around the 
vessels there are slight or extensive purulent infiltrations. In other cases there 
may also be a sero-purulent or purulent infiltration, more or less extensive, 
upon the surface and at the base of the brain. The exudate may reach the 
nerve roots or the optic chiasm at the base of the brain. The ventricles are 
often free or contain a small amount of sero-fibrinous fluid or similar material, 
such as is found upon the cerebral cortex. The ependyma is occasionally sof- 
tened and loose. Capillary extravasations, small suppurative foci, and cerebral 
abscesses are very rare. The inflammatory areas may be localized in individual 
areas of the brain, corresponding to the trauma or to disease of the petrous 
portion of the temporal bone or other carious processes of the skull. The 
inflammation is often distributed from the membranes of the brain to the 
meninges of the spinal cord. 

The most common microorganisms in the order of their prevalence are the 
pneumococcus, streptococcus, staphylococcus aureus, the bacillus of Fried- 
lander, the bacterium coli, typhoid and influenza bacilli. The pneumococcus 
is usually associated with the streptococcus and staphylococcus. 

Symptomatology. — Upon clinical investigation of the disease in the new- 
born and in children in the first years of life, we observe general or partial 



SEROUS MENINGITIS 511 

spasms which recur at short intervals without prodromes, and are accompanied 
by high fever. Following cessation of the spasm the patient becomes drowsy, 
somnolent, trembles upon the slightest noise or touch, and shrinks from the 
light, the muscles of the neck grow rigid, trismus and transitory contractures 
are occasionally noted, and the child grits its teeth. Strabismus appears, 
occasionally an ocular nerve is paralyzed, and very often there is transitory 
paralysis of the face or of the extremities, especially the legs. An important 
symptom of purulent meningitis, although by no means pathognomonic, to the 
exclusion of other cerebral diseases, is Kernig's sign : the flexion contracture of 
the knee-joint which appears when the child is placed upright in bed, or in 
the lateral posture with the thigh flexed against the trunk. The pulse and res- 
piration are abnormally increased. The great fontanelle is usually prominent. 
The glance is rigid, the eyes are partially closed, the eyeball is often in constant 
motion, the pupils are contracted or occasionally show differences in width. 
The temperature is high, 40°-41° C. (104°-105.8° F.), there is constipation, 
often vomiting, coma soon appears, and the child perishes with eclamptic 
attacks or in collapse. 

In older children we observe a decided chill, often sudden and without 
prodromes, with a high elevation of temperature. The cerebral symptoms are 
quite conspicuous. The patients complain of acute headache, which is in- 
creased by looking toward the light, often they cry aloud, and in the first two 
or three days there is frequent vomiting of bile. Constipation is a common 
symptom, but is less stubborn than in tuberculous meningitis. Delirium fre- 
quently appears upon the first or second day and is associated with audible 
sighing or increased excitement, or with fear ; sometimes it occurs a few hours 
or a few days after complete repose. During the delirious attack the face is 
often distorted, the patient cannot swallow, there is retention of urine, rigidity 
of the muscles of the neck, subsultus tendinum, and when the inflammatory 
process involves the membranes of the spinal cord there may be abnormal 
hyperesthesia, rigidity of the vertebral column, occasionally opisthotonos or 
even trismus. Partial paralyses are rare. The eyeball is sensitive to pressure, 
the pupils are at first small, but in the later course they show inequality and 
abnormal dilatation. The respiratory frequency and pulse rate, which at first 
are increased, become slower and their rhythm is irregular. In the further 
course the fever is variable, sometimes high, at other times moderate. There 
may be seeming improvement for some weeks, followed by a sudden relapse and 
fatal termination. If the patient is lifted from his bed in the first days of the 
disease and placed upon his feet, the distorted facial expression and the 
uncertain, waddling gait are conspicuous. When there is no improvement 
within the first eight days the patient passes into coma and perishes. 

Prognosis. — Acute meningitis usually terminates in death. Recovery is 
rare. If the patient does survive there will be defective intelligence or motor 
paralysis. 

Recovery from meningitis is sometimes observed when the disease occurs in 
the course of pneumonia or of otitis, and it is therefore obvious that these 



512 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

were due to a congestive condition or serous exudation. Secondary meningitis 
is frequently masked by the symptoms of the preceding disease. The menin- 
gitic symptoms may be so slight that they are overlooked. The most severe phe- 
nomena of meningitis are presented in that form which develops in the course, 
or at the onset, of otitis. Occasionally the flow from the ears ceases with the 
development of the meningeal symptoms, therefore it was formerly believed 
that if this otorrhea were allowed to take its course the development of menin- 
gitis would be prevented. This form of the disease, however, requires quick 
action and the combat of the pathologic focus while it is localized. Spontane- 
ous recovery is seldom, observed. When the outcome is so fortunate it is pos- 
sible that there was an edema or a serous exudation in the chambers of the 
brain which originated from the preceding disease of the ear. This is favored 
by a case of Eeicke's, reported by Huguenin, in which, upon the sixteenth day 
of the disease, copious serous material exuded from the right ear and a profuse 
diuresis appeared which was followed by cessation of the meningitic symptoms. 
When an exacerbation ensued, with renewed symptoms of meningitis and a 
further flow from the ear combined with excessive diuresis, recovery occurred 
with intact hearing in both ears. 

Differential Diagnosis. — It must be borne in mind that not until some days 
after the development of croupous pneumonia, occasionally only immediately 
preceding the crisis, are we able to determine whether the cerebral symptoms 
are dependent upon meningitis or are due to the croupous — so-called cerebral — 
pneumonia. The pulmonary inflammations which appear in the upper lobe, 
particularly at the apex, or which occur in the axillary fossa, are usually com- 
plicated b}^ meningitic symjDtoms. 

Tuberculous meningitis runs a more subacute course. As a rule there are 
prodromal phenomena which indicate the development of the affection, the 
fever is less and irregular, delirium is rare, and the course is slower than in 
the serous type. The anamnesis generally furnishes criteria which determine 
the nature of the meningitic disease. An accurate history and, most impor- 
tant, a careful examination of the urine, will prevent a confusion of meningitis 
with uremic convulsions. In children beyond the sixth year hysteria may 
show a transitory resemblance to meningitis if it is accidentally accompanied 
by fever, but close observation, the course of the fever, the variation of the 
symptoms, the presence of other nervous hysterical phenomena, will soon dispel 
the fear of meningitis. 

The diagnostic value of lumbar puncture will be discussed in the descrip- 
tion of tuberculous meningitis. 

Treatment. — The treatment of serous meningitis must be symptomatic and 
is never to be neglected, even in the most desperate cases. We must consider 
the sufferings of the patient and do all we can to encourage the parents and 
relatives and to avert their care and. anxiety. We must not lose sight of the 
fact that meningitis may terminate in recovery. Venesection and strong cuta- 
neous irritants are no longer employed. Lukewarm baths, cold affusions to the 
head if there is fever, Priessnitz compresses, an ice-bag to the head, calomel in 



CEREBROSPINAL MENINGITIS 513 

small doses are the remedial measures to be employed. The preparations of 
bromin and chloral in enema are indicated for their quieting effect. Inhala- 
tions of ether or chloroform should be given for the control of the convul- 
sions. In meningitis resulting from otitis media, cleanliness and thorough 
disinfection of the auditory canal are necessary, perhaps also trephining of the 
skull or opening the mastoid process and the antrum. For the otitis a few 
drops of carbolized glycerin (1-30), or a 3 per cent, boric acid solution should 
be dropped into the external auditory canal several times daily; when the nose 
is diseased the cava narium should be cleansed with a 3 per cent, boric acid 
solution, and borovaselin applied to the nasal passages. Strict antiseptic meas- 
ures are to be employed in all external lesions. 

CEREBROSPINAL MENINGITIS 

Cerebrospinal meningitis is comparatively rare in infancy; in France it is 
very uncommon, but in other European countries and in America it is of more 
frequent occurrence. The disease has a sporadic tendency, without being con- 
fined to the region of its development. The epidemic appearance, the distribu- 
tion, and the special symptoms, together with a tendency to recovery, differen- 
tiate it in a very conspicuous way from acute meningitis. The malady orig- 
inates from infection by the diplococcus intracellulars Weichselbaum, which 
Heubner has designated as the meningococcus intracellularis and which he 
regards as the only pathogenic agent of the disease. Since 1870 special study 
has been devoted to the bacteriology of this affection. In 1886 Netter demon- 
strated that the pneumococcus was frequently the cause of epidemic cerebro- 
spinal meningitis. Weichselbaum, Jager and Goldschmidt believe the diplo- 
coccus intracellularis to be pathogenic of the epidemic form of cerebrospinal 
meningitis, and Heubner was the first to observe this organism in the living 
being. In later years Finkelstein, Ftirbringer and v. Ley den have demonstrated 
the organism and Heubner has recently reported that the epidemic form 
of cerebrospinal meningitis was invariably produced in goats by injections of 
Weichselbaum's meningococcus in pure culture. This report has been con- 
firmed by many authorities. Heubner states that the meningococcus is less 
virulent than the pneumococcus, and he thus accounts for the relatively fre- 
quent recovery from cerebrospinal meningitis. The affection appears to dis- 
tribute itself in children usually by contagion, but it also occurs without epi- 
demic influence. The anatomical changes are the same as those observed in 
the sporadic cases. Upon the surface of the brain we find a thin purulent 
exudate, and in addition a suppurative infiltration of the membranes of the 
spinal cord which is most marked in the posterior areas and is localized espe- 
cially in the cervical and lumbar portions of the cord. 

Symptomatology. — The symptoms are commonly those of acute meningitis, 

often associated with acute pain in the course of the vertebral column. The 

patient complains of pain in the back and in the limbs ; the face may be either 

pale or flushed, vomiting begins early, headache is often so severe that the 

34 



514 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

patient cries aloud. The pain in the nape of the neck and in the course of 
the vertebral column is aggravated by movement and by pressure upon the 
spinous processes. There is also hyperesthesia of the skin. Rigidity of the 
back of the neck soon appears and may continue until the termination of the 
disease, occasionally combined with opisthotonos. Trismus, convulsions, sub- 
sultus tendinum, and even tetanic rigidity are sometimes noted. An eruption 
of herpes is often noticeable in the region of the face or in other areas and 
more rarely there are eruptions which resemble measles and petechia?. The 
temperature is always decidedly elevated, 40°-41.5° C. (104°-106.7° F.), the 
pulse throughout is rapid; the patient is extremely restless and soon passes 
into somnolence and coma. The pupils are contracted, the abdomen retracted, 
there is incontinence of urine and feces, and the fatal issue frequently appears 
in a few hours or days. These cases of fulminant course are often the fore- 
runners of epidemics; sometimes there is a remission in the intensity of the 
symptoms and the disease is protracted for weeks or even months, with slow 
convalescence. The percentage of recoveries is variously estimated at 25-30 per 
cent. (Florand), 63 per cent. (Netter), and 68 per cent. Recovery is not 
always complete. Often there is succeeding paralysis, contracture, deafness, 
amaurosis, or aphasia, and occasionally there are complications on the part of 
the serous membranes and the joints. 

The prognosis in cerebrospinal meningitis is grave, but not so unfavor- 
able as in the other forms. 

♦ Differential Diagnosis. — The epidemic distribution, the severity of the in- 
dividual clinical symptoms, and the microscopic appearance of the cerebro- 
spinal fluid — the presence of meningococci or of pneumococci — are determin- 
ing factors for the differential diagnosis from other forms of meningitis. 
When the disease is epidemic the patients must be isolated to prevent the pos- 
sibility of transmission to others. 

Treatment. — The treatment does not differ from that of other forms of 
meningitis. The best remedy in the epidemic form is the employment of 
Quincke's lumbar puncture. A concise description of the therapeutic meas- 
ures will be given under the treatment of tuberculous meningitis. 

The cases which terminate in deafness, blindness, deafmutism, or idiocy 
must be transferred to suitable institutions. 

TUBERCULOUS MENINGITIS 

Tuberculous meningitis is extremely common in infancy. The frequent 
occurrence, the many obstacles which may arise in the diagnosis, the localiza- 
tion of tuberculosis with its characteristic symptoms, the generally fatal prog- 
nosis when the disease has once been recognized as tuberculous, require exact 
observation and special study on the part of the physician. Moreover, there 
is the hope that we will eventually succeed in finding ways and means to con- 
trol this fatal disease which at this time we are almost helpless to combat. 

Prior to the middle of the eighteenth century our knowledge of tubercu- 



TUBERCULOUS MENINGITIS 515 

lous meningitis, or acute dropsy of the chambers of the brain, as the disease 
was formerly designated, was scant. 

In 1?68 Robert Whytt gave the first accurate description of dropsy of the 
chambers of the brain in children under two years of age. He divided the 
disease into three stages, each having individual characteristic symptoms, — a 
division which is still approved. Whytt arrived at the conclusion that the 
condition was one of acute internal hydrocephalus. The inflammatory char- 
acter of the affection was established by Quin (1780) and Ford (1790) in 
England, Bader (1790) in Germany, and Goelis (1815). The disease was 
called acute hydrocephalus until 1825, and Senn, who drew attention to its 
inflammatory nature, upon which the effusion of fluid was dependent, was the 
originator of the name u acute meningitis. " This author and Guibert had 
already recognized the granular appearance of the cerebral membranes; Guer- 
sant designated the disease meningitis granulosa instead of acute hydrocepha- 
lus, but he did not have the temerity to refer it to tuberculous nodules, assert- 
ing instead that children who suffered from acute hydrocephalus succumbed 
because they were phthisical. Guersant's pupils, Demongeot de Confevron, 
Tonnele and Pavoine, Rusz, Fabre and Constans were more exact in their 
opinion of the tuberculous character of meningitis, but the true condition was 
only made manifest by Barthez and Rilliet, who differentiated simple menin- 
gitis from the tuberculous form and called attention to the distinguishing fea- 
tures of the two diseases. They proved conclusively that simple meningitis de- 
velops invariably upon the convexity of the brain, while tuberculous meningitis 
is (almost always) localized at the base. Meningitis may appear in three forms 
(Barthez et Eilliet) : nodules, and inflammation dependent upon these; tuber- 
cles without inflammatory phenomena ; solitary tubercle in the brain and me- 
ninges. Tuberculous meningitis is often apparently primary, with prodromal 
symptoms which may be mild or severe, dependent upon a preexisting latent 
tuberculosis in other portions of the body, particularly of the bronchial glands ; 
or the affection is first observed in the course of an advanced tuberculosis else- 
where. 

Tuberculosis of the serous membranes of the brain is most common in in- 
fancy and is rare in adults. It attacks very young children, even infants of 
five months, and is largely confined to the first five years of life. The period 
of greatest frequency of tuberculosis of the meninges is variously estimated. 
Steffen mentions the second year, and Dennig ("Tuberculosis in Infancy,'' 
Leipsic, 1896) states that nurslings offer the greatest contingent. Barthez and 
Rilliet observed most of their cases in children between three and seven and a 
half years, while in 159 cases at the Strasburg Children's Clinic those between 
the second and fifth years were most frequently attacked. Contrary to the 
general opinion that boys are affected more than girls, the proportion among 
my patients treated in the hospital and in private practice is about equal. In 
my hospital there were 81 girls and 78 boys under treatment. Season appears 
to exert an influence in so far as the onset of the disease can be determined 
from the history, the months from October to May furnishing the greatest 



516 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

number of cases, and of these particularly the spring months. Steffen attrib- 
utes this to the influence of the damp, cold weather upon the lymph glands 
and respiratory passages which produces inflammation and catarrh. Predis- 
posing factors are the epidemic diseases, particularly measles, whooping-cough, 
diphtheria, scarlatina, varicella, and influenza, which are not affected by the 
seasons. I have not been able to confirm the etiologic importance of onanism 
and mental stress, which several authors, among them Barthez and Rilliet, 
D'Espine and Picot, believe to be prominent predisposing causes. Heredity is 
undoubtedly of great influence. In the pathogenesis of meningitis tuberculosa 
the neuropathic predisposition and alcoholism of the parents play an important 
role. A hereditary neuropathic predisposition is more common among the well- 
to-do classes than among the poor. Demme, Seeligmiiller, Bristowe, Mendel- 
sohn, Hilbert, Schilling, and others, mention a blow or a fall upon the head as 
causes of meningitis. If importance is to be attached to the statements of Ver- 
neuil and his pupils, every injury and every surgical operation would be a pre- 
disposing factor of tuberculous meningitis. 

Tuberculosis of the meninges is due to the colonization of tubercle bacilli 
upon the tissue of the pia mater. This is never the result of a primary 
affection, but there is always disease of neighboring or remote organs. The 
common starting-point of tuberculosis, is disease of the paratracheal and bron- 
chial lymph glands, or in tuberculous lymph glands of the neck; it may, how- 
ever, originate from tuberculous affections of the bones and joints, caseous 
processes in the lungs or in the abdominal cavity, and from diseases of the 
skin. 

By metastasis through the circulation the tubercle bacilli are swept from 
some old focus over the entire organism, and thus a general miliary tubercu- 
losis develops, tuberculous meningitis being only a part of the prevalent affec- 
tion. 

In other cases the affection is localized in the meninges, or in addition we 
may find isolated nodules in this or that organ. The development of the affec- 
tion is then usually due to caseous lymph glands, particularly the bronchial 
glands. 

However, a primary caseous tuberculous focus is not always apparent post 
mortem. We must then assume that it was not found at the autopsy and that 
some bronchial gland of normal external appearance contains Koch's tubercle 
bacilli, from which the affection started (Loomis and Pizzini). 1 

The results of these investigations lack confirmation. 

The infectious focus may also lie in the vicinity of the cerebral mem- 
branes; the disease may originate in the skull from caries of the cranial vault 
or of the petrous portion of the temporal bone, or be due to solitary tubercle 
in the brain ; further, it may arise in the nasal cavity, in the auditory canal or 

i Martens, " Traite des Maladies de l'enfance publie sous la Direction de Mm. 
Grancher, J. Comby et A. B. Marfan." — Loomis, " Researches of the Loomis Laboratory," 
1890, cited. — Pizzini, " Tuberkelbacillen in den Lymphdrtisen Nichttuberculoser." Zeit- 
schrift fur klinische Medicin, 1892, Bd. 329. 



TUBERCULOUS MENINGITIS 517 

from adenoid vegetations which contain tubercle bacilli. The infection of the 
meninges may occur by direct transmission through the lymph tracts which 
surround the nerves at the base of the brain. 

Pathologic Anatomy. — Tuberculous meningitis may appear in various 
forms. Most frequently the tubercles are distributed in the course of the ves- 
sels; the cortical and medullary substances of the brain are rarely affected. 
When the brain is removed from the skull we note that the surface, the pia 
mater, has a more or less hyper emic appearance. At the base of the brain in 
particular there are meningitic changes. Tuberculosis is usually bilateral, but 
it is often more markedly developed upon one side, especially in the region of 
the arteria fossae Sylvii. 

In addition to nodule formation there are serous, sero-fibrinous, and gel- 
atino-purulent exudations in the subarachnoid space, in the brain substance 
itself, and in the sheaths of the pia following the ventricles. With these 
changes the disease may be designated, following Eobert Whytt, meningo-en- 
cephalitis tuberculosa. If the inflammatory exudations are not present, or are 
slight, which is uncommon and occurs mostly in cases with a chronic course, it 
is better to speak of tuberculosis of the meninges. The gelatino-purulent ex- 
udate is particularly abundant around the vessels, actually enveloping them ; 
it surrounds the cerebral nerves, and completely occludes the spaces between 
the cerebral convolutions, especially the incisura fossas Sylvii. The superior 
vermis of the cerebellum and the upper portion of the medulla oblongata are 
often surrounded by a greenish, purulent exudate; the exudation is usually 
most copious in the region between the pons and optic chiasm. 

Tubercles in the pus which covers the pia mater are frequently difficult to 
distinguish and are often not perceptible until the membrane has been sprayed 
with a slow stream of water. The tuberculous nodules are most abundant in 
the course of the vessels and in the lymph tracts, particularly at their points of 
bifurcation. Sometimes distinct gray or yellowish nodules, exceptionally 
caseous masses, are found deep in the sulci. Microscopic examination reveals 
great numbers of tubercle bacilli in these nodules, also in the perivascular 
lymph tracts and in the central coagula of blood. They are also found in the 
exudate, and in one case of tuberculous meningitis Heubner found meningo- 
cocci twice and pneumococci once in the fluid obtained by lumbar puncture. 

Under the infiltrated pia the brain substance shows focal or widely distrib- 
uted softening, is reddened, and often stained by a small effusion of blood. 
Frequently there is molecular destruction of the cellular elements of the neu- 
roglia, which leads to destruction of nerve fibers and of the ganglion cells. 

If acute hydrocephalus develops the substance of the brain is softened 
and edematous, and the veins show injection. The amount of ventricular fluid 
varies proportionately between 20 and 100 c.c. The fluid is most copious in 
the lateral ventricles, but is also found in the third and fourth ventricles, 
sometimes clear, occasionally turbid, with admixture of fibrin flocculi; it is 
seldom purulent. Under treatment, especially in the discussion of lumbar 
puncture, I shall recur to the composition of the ventricular fluid. 



518 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

The choroid plexus is reddened, swollen, enlarged, and sometimes softened. 
The changes of the choroid plexus eventually play a role in the development of 
hydrocephalus. By pressure of the ventricular fluid upon the suhstance of the 
brain the gyri are separated, the sulci obliterated, the subarachnoid fluid is ex- 
pressed, the cortex of the brain becomes anemic, and the arachnoid surface dry. 

Isolated nodules are also found in the convexity, upon the pia. Occasion- 
ally numerous nodules with a gelatin o-purulent exudate are observed in the pia 
sheaths, now and then with small, localized foci of inflammation or softening 
in the brain. The convexity of the cerebellum may also be involved. The 
dura mater is often permeated with tubercles, particularly at the base of the 
skull over the sella turcica. In the convexity the tubercles are always on the 
inner surface of the dura mater. Exceptionally, under the influence of the 
tuberculous infection there is a development on the dura mater of pseudo- 
membranes which are permeated by hemorrhages. Larger tubercles are not 
uncommon. In some cases they are altogether absent and there is merely an 
inflammation of the pia. In tuberculous meningitis the membranes of the 
spinal cord are usually involved. According to v. Leyden the greater develop- 
ment of the inflammatory process on the posterior surface of the spinal cord 
membranes is due to gravity, but Erb " regards this preference of the posterior 
surface of the cord as due to the numerous meshes and septa of the posterior 
subarachnoid space which have been observed by Axel Key and Betzius." The 
essential reason therefor is the direct relationship of the arachnoid sac of the 
brain and spinal cord ( v. Leyden ) , and the constant movement of the cerebro- 
spinal fluid, as was demonstrated experimentally by Quincke, is the factor 
which propagates the inflammation from the brain to the spinal cord and vice 
versa. 

The spinal cord is often involved in the same manner as the brain, in that the 
tuberculous inflammatory process, through the agency of the pia, which sends 
its branches to the nerve substance beneath, is propagated to the spinal cord. 
But it also appears that the tuberculous affection of the meninges is dependent 
upon tuberculosis of the vertebra and is then distributed from the membranes 
of the spinal cord to the meninges of the brain. The emerging nerves and the 
nerve roots are often involved. Microscopic examination reveals that we are 
dealing with the development of nodules or with a tuberculous infiltration of 
the pia spinalis, with frequent implication of the spinal ganglia. The axis 
cylinders are sometimes swollen, sometimes they show granular degeneration, 
the medullary sheaths are degenerated, the spinal cord shows in some cases a 
beginning acute interstitial myelitis (Schultze). This explains certain of the 
symptoms of meningitis, such as hyperesthesia, anesthesia, and paralysis. 
Changes in the eye-ground are common, as well as venous hyperemia of the 
retina and optic neuritis with terminating atrophy. Choroid tubercles are 
rarely observed. 

Symptoms and Course. — Tuberculous meningitis is either a partial phe- 
nomenon of general miliary tuberculosis or the meningitic symptoms develop 
with cerebral phenomena and without tuberculous involvement of other or- 



TUBERCULOUS MENINGITIS 519 

gans. This form of the disease occurs principally in childhood and is to be the 
subject of our further discussion. 

The symptom-complex of tuberculous meningitis has been divided by vari- 
ous authors into definite periods. Thus R. Whytt proposes three divisions, 
regulated by the condition of the pulse. Goelis distinguishes a stage of tumes- 
cence to the head, of local inflammation of the membranes or brain substance 
or of both simultaneously, of transudation following inflammation, and of 
paralysis. Plenk and Henke designate the first period " febrile," the second 
" apyretic," the third " lethal." Among more recent authors Steffen, following 
Traube, divides the course of the disease into a stage of irritation, of pressure, 
and of relaxation. Yogel and Henoch assert that an attempt at such a division 
is futile, as there are too many deviations from the typical course. It is well 
to omit a 'division into definite periods and, like Henoch, to merely differen- 
tiate the stages of irritation and of paralysis. 

The character of the pulse follows a definite rule throughout, therefore, fol- 
lowing the arrangement of Whytt (Rilliet et Barthez, Votteler), I shall next 
give a description of the individual symptoms as they arise prior, during, and 
subsequent to the period of slow pulse. 

The first of these is headache, which in the prodromal stage is not per- 
sistent. The head is grasped with the hands or inclined to one side, the facial 
expression denotes pain, and the child often moans or cries, " My head ! My 
head ! " Older children complain of headache now and then, which may be so 
intense that they cry aloud ; the pain may appear in paroxysms and be exacer- 
bated by intense light. As a rule it is localized to the frontal region and either 
disappears with increasing stupor or the patient is less conscious of it. Fre- 
quent crying and grasping of the head apparently denote the presence of head- 
ache even in the somnolent condition. The pain ceases, but constantly recurs 
in varying intensity. Headache may be regarded as the expression of an in- 
creased intracranial pressure (Emminghaus), the arachnoid portions of the 
pia (after displacement of the minimal quantity of subdural fluid, which was 
demonstrated by Hitzig) being pressed toward the fibrinous layer, which Hit- 
zig claims is rendered highly sensitive by the ramifications of the trigeminus 
and pneumogastric nerves. As a rule, at the beginning of the disease infants 
do not take the breast so regularly as in health, the patient emaciates and 
the skin becomes pallid and wrinkled, notwithstanding the sufficient ingestion 
of food; in other cases nourishment is taken irregularly. The child soon lets 
go when put to the breast, falls asleep, cries upon renewed attempts to make it 
suckle, and soon slumbers again. 

The tongue is sometimes coated, and diarrhea alternates with constipation. 
Sleep is restless, often interrupted by sudden outcries. The eyes are languid, 
dim, the countenance denotes suffering, occasionally the child cries aloud; but 
not until the appearance of more serious symptoms, such as severe headache or 
convulsions, is the physician consulted. The whole nature of older children 
is frequently changed. Those who are naturally active become quiet, ill-hu- 
mored, and protect the head or bury it in the mother's lap. Others are fidgety 



520 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

or sit in a corner, feel too weak to walk, mope, become listless, and refuse to 
take part in the games of their playmates. They are depressed, fretful, dis- 
satisfied with everything, cry upon the slightest provocation, are disagreeable, 
quarrelsome, and disobedient. Sleep is usually restless and ofttimes inter- 
rupted by fright or loud outcries. At school these children are listless, 
confused, and cannot follow the instruction. Appetite is usually poor or irregu- 
lar, the bowels are often constipated, or there may be diarrhea. These condi- 
tions are frequently well developed; again they are insignificant and raise no 
suspicion of the gravity of the affection until a difference in the pupils, a tran- 
sitory strabismus, and increasing pain cause the parents to consult a physician. 
The prodromal symptoms, which are of varying intensity, are referred to 
hyperemia of the pia brought about by miliary tuberculosis. The affection 
may, however, develop in quite the same manner as epidemic cerebrospinal 
meningitis, with high fever and slow pulse, or the pulse may be abnormally 
rapid or intermittent. The child passes rapidly into stupor and coma with 
continued high fever, and life is soon extinguished. Cases are on record which 
terminated in ten hours (Dennig), in two hours (Rohrer), and in four and 
one-half hours (Seeligmuller). 

The onset may be acute and followed by a cessation of the symptoms for 
several weeks (Dennig) ; then the cerebral symptoms appear and the case ter- 
minates in death. 

Vomiting usually accompanies the headache and general symptoms. It 
occurs independently of the ingestion of food and is sometimes observed as 
often as seven times in the course of the day. It appears abruptly, without 
preceding nausea, and is copious, or it may be superseded by retching. Vom- 
iting is induced by quick elevation to the sitting posture and also after inges- 
tion of fluid. The vomitus is often bile green, sometimes admixed with 
mucus and at first with particles of food. This symptom appears with the 
early meningitic phenomena, continues one or more days, then usually disap- 
pears and is rare after the first week. Vomiting is by no means pathognomonic 
of tuberculous meningitis, but when it appears suddenly and without cause it 
occupies an important position in the diagnosis in connection with the history 
and the accompanying symptoms. It is then probably due to an irritation of 
the vomit center in the medulla oblongata (Hermann, " Physiology/' p. 136) 
which is produced by hyperemia, reflex anemia, or other influences. 

Constipation occurs simultaneously with vomiting, or precedes it, and fails 
to yield to the strongest purgatives. This sluggishness of the intestines is 
almost exclusively peculiar to meningitis, and is observed together with scaph- 
oid (retracted) belly, — one of the most important phenomena of tubercu- 
lous meningitis. The cause of the constipation has not been determined. It is 
probably due to an irritation of the splanchnic nerves (Henoch, Barthez and 
Rilliet) — the nerves of inhibition of intestinal movements; the peristaltic 
movements are very sluggish or are difficult to detect under the emaciated 
cutaneous coverings of the belly. The vomiting, constipation, the retraction 
of the abdomen probably have a common pathogenesis. Vogel is of the opinion 



TUBERCULOUS MENINGITIS 521 

that the retracted belly is the result of a constant pathologic contraction of 
the transverse and oblique muscles. Very few of my cases showed a contrac- 
tion of these muscles. 

Slight, irregular fever is present from the beginning of the disease, the 
temperature rising in some cases to 39° C. (102.2° F.) in the late afternoon 
hours. Xow and then, however, the elevation is higher, 40° to 41° C. (104°- 
105.8° F.), and remains so throughout the twenty-four hours. The pulse is 
at first rapid and irregular, with quick fluctuations both in frequency and ful- 
ness. After the introduction of cerebral symptoms, as somnolence, the pulse 
is slower — 60 to 80 beats — and of irregular rhythm, sometimes intermittent. 
The slight movements of these patients, the turning in bed, and also mild 
psychical irritation, are sufficient to stimulate the pulse frequency materially, 
the pulsations increasing to 140-160 per minute. 

To these symptoms photophobia must be added. The patients are apa- 
thetic, close their eyes, turn their faces to the wall, and are annoyed by all 
sounds. When questioned by the physician or relatives they grow restless, turn 
away in fear, or moan and cry aloud. They whimper and frequently exclaim, 
" My head ! My head ! " and grasp some portion of the head with their hands. 
There is hyperesthesia of the skin and the muscles ; mild cutaneous irritation is 
sufficient to provoke crying. Pressure upon the eyeball is painful. Although 
sleep is essential, it is an impossibility. In a half-awake condition they rise 
suddenly, sit upright in bed and gaze about. Delirium is rarely an accompa- 
niment of this symptom in children. From time to time deep sighs are heard. 
The apathetic condition passes gradually into somnolence, interrupted fre- 
quently by loud crying (cris hydrencephaliques, Coindet), the eyes are par- 
tially closed with the bulbi rolled upward and inward. When called loudly 
the patients show but slight consciousness or give brief or unintelligible replies 
and lapse again into stupor. They then assume the so-called '''hunting-dog 
posture " : the trunk is inclined forward, the thighs are drawn up against the 
lower abdomen, the back of the neck is stiff, occasionally there is a well-devel- 
oped rigidity of the neck. 

The appetite fails, fluid nourishment only is taken, there is no apparent 
increase of thirst, the tongue is coated. Emaciation is rapid and extensive. 
When somnolence is well marked the patients refuse food, and if trismus devel- 
ops, with an arrested deglutition reflex, the only recourse is artificial nourish- 
ment with a stomach tube. The urine is scant, but free from albumin. The 
liver and spleen are occasionally enlarged. 

During the second iceek of the disease the entire pathologic picture is 
changed, together with the disappearance of vomiting and of severe headache. 
The fever decreases, sometimes to the normal temperature. The pulse be- 
comes slower and is irregular. During examination of the pulse we must 
palpate cautiously, for any excitement is sufficient to send the pulse from 60 
to 140, or even 160, beats per minute. Such abnormal slowness of the pulse 
in a febrile disease is noted only in tuberculous meningitis [and yellow fever']. 
Respiration is irregular ; deep, long-drawn inspirations are followed by those of 



522 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

short, superficial, rapid character. The breathing may cease and begin again 
with a deep sigh. Deep and shallow breathing alternate. Occasionally the 
Cheyne-Stokes type prevails — the respiration becomes slower, intermittent, and 
interrupted with sighs. 

Vasomotor symptoms may be noted. The color of the face shows great 
variation. Flushing and pallor alternate rapidly. Large red splotches may 
suddenly appear on the face, increase in size, and in a short time vanish. 
Slight cutaneous irritation with the finger or a pencil drawn over the surface 
at once produces red welts in the path of irritation, which distribute them- 
selves and after a while disappear. Trousseau, who first described this phe- 
nomenon, erroneously regarded it as pathognomonic of meningitis and des- 
ignated the symptom " tache cerebrate" or " meningitique" Exanthems are 
rarely observed in tuberculous meningitis, although urticaria, roseola, and 
other eruptions resembling measles are sometimes seen. Herpes labialis and 
herpes zoster are occasional phenomena. In the course of the disease purulent 
eczemas not infrequently dry, profuse secretion of the nasal mucous mem- 
brane ceases, and the early diarrhea disappears (Henoch). The swelling of 
the cervical glands is reduced, often within a few days, under the influence of 
meningitis (Henoch). Occasionally there are profuse outbreaks of sweat, 
perhaps unilateral, and for a few days prior to death the face may be bathed 
in perspiration. 

Ocular changes are conspicuous from the outset. Even in the first days of 
the disease the luster of the eye peculiar to children is lost, the glance is often 
fixed, dreamy, and when somnolence appears it is expressionless.' Photo- 
phobia is common. The eyeball is sometimes rolled upward and inward, and 
there is convergent strabismus, which vanishes when the child is recalled to 
consciousness by loud talking — a condition, however, which Rahlmann and 
Wittkowski claim is not unusual in childhood during sleep. Divergent strabis- 
mus may also be present. Whether or not there is double vision cannot be de- 
termined because of the involvement of the sensorium. The strabismus is 
usually transient. Incomplete closure of the lids and anesthesia of the cornea 
due to paralysis of fibers of the fifth nerve cause an over-exposure of the sclera 
and cornea to the air and a consequent dry appearance, and the eye may be 
covered with a thick conjunctival secretion. Later the cornea becomes uneven, 
clouded, but is rarely ulcerated or destroyed. Toward the end of the affection 
the sclera shows injection of the venous vessels. At first the pupils are usually 
contracted, later they are dilated and often reveal a transitory inequality. 
Without apparent cause a normal pupil will be widely dilated and subse- 
quently show decided contraction. Pupillary reaction, although slow, is gener- 
ally retained. When cutaneous irritation is marked a transitory dilatation 
of the pupils is frequently produced by pinching the skin. N"ow and then 
there is nystagmus, the movement of the eyeball being undulated and oscil- 
latory, in other cases these movements are spasmodic, rhythmic, occurring 
about 70 times a second. With the development of rapid pulse the pupils 
commonly assume their normal width; they may, however, be markedly con- 



TUBERCULOUS MENINGITIS 523 

tracted, especially in deep coma. The reaction to light is then usually lost and 
a ray of light near the eyes fails to induce closure of the lids or pupillary reflex. 
Neither the retina nor the optic nerve can be stimulated. Amblyopia and 
amaurosis appear. 

During general convulsions the pupils are dilated and in the intervals they 
contract. The origin of pupillary changes is very complex and it is difficult to 
determine whether the sympathetic or the oculomotor nerve exerts alternately 
a stimulating and paralyzing influence upon the width of the pupils. The 
irritative and paralytic phenomena may be due to an increase of the intracra- 
nial pressure and to direct inflammation, and in that case the nerve centers or 
the nerve fibers are affected in their course. 

Opthalmoscopic examination seldom reveals choroid tubercles. 

The eye-ground is often normal. In other cases we find slight hyperemia 
of the eye-ground with a normal, clearly defined pupil, or venous hyperemia of 
the retina and often slight choked disc. Optic neuritis, occasionally terminat- 
ing in atrophy, may also be observed. 

The explanation of the inflammation of the papillae may be found in the 
relation of the arachnoid to the subvaginal space (Schwalbe), and Virchow 
was able to demonstrate perineuritis and interstitial neuritis in the course of 
the optic nerve. As to the diagnostic value of the ophthalmoscopic findings 
I may state that changes in the eye-ground are usually not conspicuous until 
other symptoms have arisen which unquestionably indicate tuberculous men- 
ingitis. 

In doubtful cases running an abnormal course ophthalmoscopic investiga- 
tion may occasionally be of assistance in the diagnosis. 

During the second week irritative phenomena, transitory convulsions, and 
general or partial contractions appear. Muscular contractions of the face and 
of the e} r elids, nystagmus, trismus, movements of sucking and of mastication, 
gritting of the teeth, or tonic or clonic spasms of the extremities are observed. 
In the last condition special muscle groups are implicated or the entire body 
is involved. The spasms are of varying intensity; they may continue for an 
indefinite time, then cease for a few hours or days, and begin anew. During 
the intervals there may be contracture in various muscle regions, particularly 
of the adductors of the thigh and the flexor muscles of the upper arm. Pick- 
ing of the bedclothes is also common. In addition there is marked rigidity of 
the neck, the head is frequently burrowed deeply into the pillows, opisthotonos 
may be present and is sometimes so extreme that the stiffened body can be 
raised by pressure of the hand under the head. 

Rigidity of the neck is always associated with pain over the cervical verte- 
brae induced by pressure. Occasionally there is a relaxation of the muscles of 
the neck which permits movement of the head, but the painfulness continues. 
The younger the child the earlier is this symptom apparent. In regard to the 
nature of this rigidity I must remark that according to v. Leyden it is the 
consequence of an implication of the medulla oblongata or of the upper por- 
tion of the cervical cord, not, however, of spinal meningitis. Inversely 



524 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

opisthotonos is a symptom peculiar to diseases of the spinal cord membranes 
dependent upon contracture of the muscles of the back. Opisthotonos is par- 
ticularly prominent in cases which run their course with high fever. Rigidity 
of the neck and of the vertebral column frequently vary in intensity, some- 
times to a complete relaxation of the contracture. External irritation may 
reproduce the opisthotonos. This symptom is always associated with contrac- 
tures in the lower extremities, particularly with rigidity of the adductors of the 
thigh, and sometimes with contractures of the muscles of the arms. Coma 
is present in all cases. Occasionally the hydrocephalic cry of Coindet is heard. 
This is not due to a conscious sensation of pain, but is purely automatic 
(Trousseau). 

In this period of the disease the patient lies quiet, the fever abates or dis- 
appears, the pulse rate is decreased, the headache and hyperesthesia are less 
intense, and vomiting has ceased. Those around the patient believe that he is 
better and hope is awakened that his life will be spared. The experienced phy- 
sician, however, will not be misled by this apparent improvement. 

In the terminal stage sopor or coma is combined with paralysis or convul- 
sions. The last condition occasionally is limited to an extremity, often a mere 
contraction, while in other cases general spasms are observed. In addition fre- 
quently there are paralytic symptoms, usually mild, which involve one or 
another extremity and are sometimes associated with paralysis or paresis of the 
facial, the oculomotor, or the abducens nerves. Paralysis of the facial or of 
the ocular nerves, however, is frequently observed without simultaneous paraly- 
sis of the extremities. This symptom is largely due to an exudate surrounding 
the nerves at the base of the brain. Occasionally the necropsy shows no dis- 
tinct changes. In tuberculous meningitis, however, there are permanent 
paralyses due to focal disease of the brain, softening, obliteration of the 
arteries, or to solitary cerebral tubercle. According to the localization we find 
hemiplegia, monoplegia, or crossed paralysis. 

The patients lie in bed with eyes widely opened, or the glance is half veiled. 
The pupils, which were previously dilated, contract and do not react to light. 
There is amaurosis, the patient no longer shows consciousness, reacting neither 
to a call nor to mechanical stimulation. The sudden changes in the color of 
the skin are conspicuous; flushing and pallor rapidly alternate. Although 
these symptoms are present in the first weeks of the disease they do not become 
prominent until toward the end of the second or early in the third week, or at 
the close of the second or the beginning of the third stage. The skin is 
shrunken and dry, the adipose tissue indicates wasting, and at times an ery- 
thema appears over the entire body. 

Contraction of the abdomen becomes so prominent that the abdominal 
covers almost lie upon the vertebral column. Toward the end the temperature 
of the skin increases; in the rectum it may register 40° to 43° C. (104°-109.4° 
F.). The pulse is rapid (160-200) and with decrease of cardiac power marked 
cyanosis appears, the skin is often covered with cold, clammy perspiration, the 
respiration is hurried and irregular, sometimes of the Cheyne- Stokes type, 



TUBERCULOUS MENINGITIS 525 

feces and urine are voided involuntarily, and gradually, perhaps with pre- 
ceding general spasms, life ebbs away. The post mortem temperature is almost 
always high, and in the rectum may be 43° C. (109.4° F.). 

This is the general picture of tuberculous meningitis. The disease, how- 
ever, presents no uniform course, one or another characteristic symptom often 
being absent. The headache and vomiting may be slight or fail to appear; 
fever may not occur until toward the end of the disease; the convulsions, 
paresis of the oculomotor, abducens and sympathetic nerves need not occur; 
but the nature of the disease is evident to the skilled physician without a com- 
plete symptom-complex. 

A further condition which is often found at the onset of the affection in 
nurslings and in children during the first two years of life is eclampsia, asso- 
ciated with somnolence, which may again be interrupted by renewed attacks 
of spasm, sometimes accompanied from the onset by temporary rigidity of the 
neck. This condition is succeeded by a rapidly developing coma and death 
follows in the course of three or four days. In other cases, especially in 
adults and in older children, the meningitic symptoms arise suddenly in the 
course of well-advanced pulmonary tuberculosis or tuberculosis of other parts 
of the body, especially of the bones. In adults this condition is frequently 
associated with delirium — a rare phenomenon in children — and the patient 
perishes in a day or two. 

Partial meningitis may develop primarily or as a secondary affection. The 
symptoms are similar to those of general meningitis, combined with other 
phenomena such as spasms and paralysis which are dependent upon the seat 
of the disease. Here we observe convulsions, various paralyses of the eyes and 
face, monoplegia or paresis, hemiplegia and paraplegia, with and without con- 
tractures. The development of these paralytic phenomena may be slow or 
apoplectiform and is the result of analogous conditions such as are noted in 
solitary tubercle of the brain. 

The membranes of the spinal cord are involved in most cases of tuberculous 
meningitis. The spinal symptoms, however, are dominated by those of basilar 
meningitis. The patients occasionally complain of pain in the lumbar region 
and of a disagreeable, tormenting sense of constriction as though the thorax 
were compressed and the chest bound with hoops [girdle pain]. Eadiating 
pains are sometimes felt in the lower extremities, with hyperesthesia of the ab- 
dominal walls, muscular contractions, and subsultus tendinum. Marked rigidity 
of the vertebral column, opisthotonos, increased reflexes, and even a complete 
tetanus are observed. In the later course, after the pains have lessened, the 
paralytic phenomena of the lower extremities and of the bladder predominate. 

Prognosis. — Tuberculous disease of the meninges offers a very serious prog- 
nosis. Quite exceptionally there may be an arrest of the tuberculous process, 
or there may be a prolonged quiescence of the symptoms, but after a few weeks, 
infrequently after months, the symptoms of meningitis recur and the patient 
succumbs. When there is actual recovery the doubt always remains whether 
we were dealing with true tuberculosis. 



526 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

In some patients who present the symptoms of tuberculous meningitis the 
acute inflammatory phenomena occasionally subside and there may be, as we 
know, calcification and encapsulation of the tuberculous focus, and infiltration, 
but the further consequence of these chronic changes manifests itself in the 
form of idiocy and epileptic attacks (Marfan). A few authors have noted 
recovery of cases in which tubercle bacilli were demonstrated microscopically in 
the lumbar fluid (Leube, Freihan, M. Henkel). As to the value of lumbar 
puncture in tuberculous meningitis, we must admit that an arrest of the tuber- 
culous process in the membranes of the brain may occur in isolated cases of 
tuberculous meningitis even without therapeutic aid, as is now and then dem- 
onstrated at the post mortem table after the lapse of years. 

In my hospital and private practice not one of the cases in which I have 
made a diagnosis of tuberculous meningitis has been saved even by lumbar 
puncture. 

Diagnosis. — The diagnosis does not cause much perplexity. A careful his- 
tory, a minute examination and cautious observation of the course of the symp- 
toms, will protect us from error. As has been already explained, even though 
one or another symptom may be absent, the individual phenomena eventually 
group themselves into a pathologic picture which permits a positive diagnosis 
of tuberculous meningitis. The gradual development of the disease, early 
irregular fever which soon terminates with a fall of temperature to normal and 
below, the condition of the pulse, its retardation and irregularity and the suc- 
ceeding abnormal rapidity which sets in at the end of the second or the begin- 
ning of the third week, the severe headache, the paralysis in the course of the 
ocular and facial nerves, the inequality of the pupils, the somnolence which 
appears later, the spasms, the coma are sufficient to determine the diagnosis. 

Certain difficulties may arise in the differentiation from febrile gastric 
affections which at their onset occasionally simulate meningitis. Children 
complain of headache and pain in the abdomen, there is vomiting and consti- 
pation, the appetite is poor, the tongue coated, and often there is conspicuous 
photophobia. In addition there may be irregular fever, ranging from 38° to 
38.5° C. (100.4° to 101.3° F.), and increased but regular pulse. Such affec- 
tions usually begin acutely and may often be attributed to indigestion. The 
patient is fretful and cries, and the physician may suspect the development of 
severe meningitis. The further course, however, will reveal the correct diag- 
nosis. In a simple febrile gastric catarrh the pulse is not retarded and irregu- 
lar, as in meningitis, but remains rapid and small, although in convalescence, 
when all other symptoms have disappeared, a certain transitory irregularity 
may be noted. 

Enteric fever sometimes presents the symptoms of meningitis, now and then 
combined with aphasia and unilateral paralysis. If it is doubtful whether we 
are dealing with enteric fever or meningitis an examination of the blood for 
the Widal reaction, and lumbar puncture, will decide the question. 

Other forms of meningitis which appear in the course of infectious dis- 
eases, or owe their origin to otitis or to affections of the nose or pharynx, can 



TUBERCULOUS MENINGITIS 527 

readily be differentiated if we take into consideration the foregoing disease and 
carefully examine the ears and the nasal and pharyngeal cavities, which will 
reveal at once whether we are dealing with a tuberculous or other form of men- 
ingitis. 

Cerebrospinal meningitis, in contrast with meningitis tuberculosa, is usually 
of acute onset, without prodromes, and with high fever. The spinal symptoms 
are most prominent — abnormal rigidity of the vertebral column, contractures 
of the muscles of the extremities, tremor, subsultus tendinum — and the disease 
usually presents an epidemic tendency from the beginning. Lumbar puncture 
may enlighten us as to the nature of the meningitis. According to the investi- 
gations of E. Bendix (Deutsche Tclin. Wochenschr., 1901, No. 43) the cytologic 
quality of the cerebrospinal fluid furnishes a positive means of differentiation 
of tuberculous from purulent or epidemic meningitis. In five cases of tubercu- 
losis of the meninges which were treated in Prof. Minkowski's wards in the 
Augusta Hospital in Cologne it was invariably noted that the cellular elements 
of the cerebrospinal fluid consisted largely of small, mononuclear pus corpuscles 
- — lymphocytes — and that the large polynuclear leukocytes were scarce. In- 
versely, in purulent or epidemic meningitis the leukocytes preponderate. 

The differentiation of meningitis simplex from meningitis tuberculosa may 
occasionally be perplexing. The acute development, the convulsions which 
often appear at the onset of the disease, and the uniformly high fever 
favor the former affection. Tuberculosis of the meninges may exceptionally 
present the same clinical picture as simple meningitis, therefore when the 
patient's relatives report trauma as the cause of the disease, and a hereditary 
predisposition cannot be established, the differential diagnosis for the time 
being is impossible. The presence of tubercle bacilli in the lumbar fluid is a 
positive diagnostic factor. 

The differential diagnosis of tuberculous from syphilitic meningitis in chil- 
dren as a rule cannot be made. The favorable progress of the disease follow- 
ing the employment of mercurial preparations, calomel, and inunctions would 
indicate the syphilitic form. 

Symptoms suggestive of meningitis may occasionally be noted in helminthi- 
asis. An accurate history and careful observation will protect us from error, 
and if there is a suspicion that such symptoms as vomiting, headache, vertigo, 
fretfulness, irregular pulse, etc., are brought about by the irritation of worms, 
the administration of santonin or other suitable vermifuge, together with calo- 
mel, will soon give us an insight of the nature of the affection. 

Treatment. — Tuberculous meningitis must be designated as an incurable 
disease. I have never seen recovery, and the cures reported by other authors 
(among them Politzer, Bokai, Henoch) were soon followed by relapse. 

It would, however, be inhumane to at once predict this unfavorable out- 
come to those about the patient, as errors may be made in diagnosis ; we must 
not discourage all hope of a favorable termination, and a positively lethal prog- 
nosis should be withheld until we find that the patient is passing constantly 
from bad to worse and that the only relief will be death. We must not content 



528 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

ourselves with therapeutic nihilism. Calomel may be given in small doses for 
relief of the constipation ; inunctions with unguent, hydrargyri should be tried. 
If, however, there is an eventual favorable result we will have to admit that 
we were not dealing with tuberculous meningitis, but with a meningitis of 
syphilitic origin. According to Quincke mercurialization by inunctions with 
blue ointment, which should be continued from four to six weeks, is very bene- 
ficial in the serous form of the disease. 

The common therapeutic measures, as leeches, ice, and calomel, have no 
noteworthy influence, and this is also true of resorbents and derivatives. In- 
unctions to the nape of the neck or upon the scalp with strongly irritating 
ointments such as tartar emetic ointment, unguent, veratrinae, guaiacol oint- 
ment 10-15 per cent., and painting with tincture of iodin are more annoying 
to the patient than efficacious. 

The treatment must be purely symptomatic and directed principally to the 
alleviation of pain, decrease of restlessness and of the irritative phenomena, 
the relief of spasm with its accompanying pain, and the control of constipa- 
tion; further, we may attempt to reduce the pyrexia and administer sufficient 
nourishment, so far as this is practicable. 

The application of an ice-bag to the head occasionally lessens the pain ; but 
if this cannot be controlled, small doses of morphin or codein may be given, or 
hypodermic injections of morphin up to 4 Mgs. For the relief of severe spasms 
enemata of chloral hydrate are of service. (0.05-0.5-1.0 to 50 of distilled water 
or decoction of althea). If there is high elevation of temperature baths at 34° 
C. (93.2° F.) and gradually reduced to 30° C. (86° F.) by the addition of cold 
water, are indicated. The mouth should be carefully cleansed and if conjunc- 
tivitis and keratitis develop, a protective dressing is absolutely necessary. 
Nutritive enemata are sometimes useful. 

For retention of urine warm fomentations may be applied to the abdomen, 
or the bladder should be emptied by catheterization. In conditions of collapse 
such as fall of temperature, marked cardiac asthenia, and coma, warm baths 
with cold affusions are indicated. Thus far no favorable result has been ob- 
served from injections of tuberculin. 

Nothing is to be expected from trephining of the skull or puncture of the 
lateral ventricles. 

On the other hand we should endeavor to bring about amelioration, or re- 
covery perhaps, by lumbar 'puncture, which was introduced by Quincke in 1891 
and is carried out according to his well known directions. 1 This is gen- 
erally performed in the third interarcual space between the third and fourth 
lumbar vertebrae, in either the right or the left lateral position, with the 
body inclined forward, the knees flexed against the abdomen so that the 
vertebral column is curved and the spinous processes are prominent. 
The needle is inserted in the median line to a depth of 2 to 4 cm., according to 
the age of the child. If fluid does not appear the needle may be directed 

i See article on Lumbar Puncture by Quincke in the volume on " Diseases of the 
Nervous System," p. 223. 



TUBERCULOUS MENINGITIS 529 

slightly upward. I have never seen sudden death follow these maneuvers, nor 
have I observed serious consequences such as hemorrhage, convulsions, deviation 
of the needle, false passages. The quantity of fluid obtained by puncture 
varies from 4 to 100 c.c. (Therap. Monatsh. 1900.) The pressure ranges from 
180 to 750 Mm. water. 

The value of lumbar puncture depends primarily upon whether the pres- 
sure is increased and the quantity of fluid is excessive. The amount of albu- 
min contained in the cerebrospinal fluid in these cases shows an average varia- 
tion of J, J and 1 per 1000; in one instance it was 2^ per 1000. I have 
never found sugar. The specific gravity ranges between 1002 and 1008. The 
fluid is usually clear; occasionally I have seen a slight turbidity. After 
standing a few hours the water-clear fluid sometimes shows a slight floccular 
precipitate. The tubercle bacillus is not always demonstrated upon bacterio- 
logic investigation. According to the reports of various investigators this 
microorganism is found in 50 to 80 per cent, of the cases. In general miliary 
tuberculosis, in solitary cerebral tubercle, and in general tuberculosis of other 
organs, the cerebrospinal fluid will very often be found sterile. I do not attach 
much value to the presence of tubercle bacilli in the lumbar fluid, as in tuber- 
culous meningitis the entire course, the character of the fever, and the basilar 
brain symptoms are sufficient for a positive diagnosis without the employment 
of lumbar puncture or an examination of the eye-grounds (choroid tubercles). 
Bacteriologic investigation of the lumbar fluid is of great importance in deter- 
mining the nature of the meningitis, whether tuberculous or suppurative. 

Some therapeutic value may be attached to lumbar puncture from the fact 
that for a brief period following this slight operation the patient occasionally 
awakens from coma, sits up in bed, asks for food and drink and shows a tran- 
sitory interest in his surroundings. Xevertheless there is an eventual relapse. 
Spasms may cease and we gain the impression of a decided improvement. I 
have never been able to demonstrate a permanent benefit from lumbar punc- 
ture in tuberculous meningitis, and although some authors (J. Schwalbe, 
Leube, Freihan, Henkel) have reported recovery following that procedure, nev- 
ertheless when we consider its therapeutic influence we must remember that 
in very exceptional instances an arrest of the tuberculous process in the cere- 
bral membranes may take place even without therapeutic aid, as is demon- 
strated now and then at the post mortem table days and weeks or even years 
after the condition had occurred. However, taking into consideration the tran- 
sitory relief by lumbar puncture of the most distressing symptoms (delirium, 
pain, convulsions, outcries), I would always favor this method. It relieves not 
only the patient, but those about him; the relatives again hope for improve- 
ment and feel that help is still available; it saves the physician from complete 
powerlessness in this otherwise dreadful and fatal disease, and to some degree 
at least alleviates the suffering. 

I have seen favorable results from lumbar puncture in purulent cerebro- 
spinal meningitis. The cerebrospinal fluid contained meningococci or diplo- 
cocci. Of six patients upon whom I performed lumbar puncture for suppura- 
35 



530 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

tive meningitis two were cured, the third case, apart from complete deafness, 
was discharged from the hospital quite well, the fourth, a weak, rachitic 
child, recovered from meningitis, and showed normal hodily development but 
was deficient mentally and is not yet able, although five years old, to stand 
alone or walk. These favorable results coincide with those of Netter, who 
reported recovery in 7 out of 11 cases of purulent meningitis, the diagnosis 
having been made by lumbar puncture. 

Recovery occurred as a rule in five to fourteen days, but in some cases 
required two or three months. 

Netter repeated lumbar puncture in his patients from one to ten times. 
He believes that the favorable result of puncture is reinforced by the employ- 
ment of hot baths of twenty to thirty minutes' duration, at a temperature of 
38° to 40° C. (100.4° to 104° P.), repeated every three or four hours day and 
night. I have observed no noteworthy influence upon choked disc, as has been 
reported by some authors, among them Landolt (Strasburg). Attention must 
be devoted to the nutrition of such patients, and if there is decided loss of 
strength subcutaneous infusions of normal salt solution are indicated. 

In serous meningitis the views as to the benefit of lumbar puncture are 
widely diverse. Quincke, Heise, Henschen, and v. Leyden report good results ; 
on the other hand Fiirbringer, Pott, and Fleischmann have seen no favorable 
effect from lumbar puncture and have known disagreeable symptoms to follow 
the procedure. Nevertheless this slight operation should always be performed, 
and I must particularly advise its repetition after a few days, with proper anti- 
septic precautions, and that each time only a small quantity of fluid, 30 to 50 
c.c, should be withdrawn. 

In chronic cases a slitting of the dura mater by means of a long-handled 
knife with a blade 4 to 6 Mm. wide, may be of service. The knife is introduced 
in the same manner as the needle, and immediately following it in the next 
lower interarcual space, or the operation may be done a few days after the 
lumbar puncture. 

Trephining of the skull and simple splitting of the dura mater, or puncture 
of the ventricles, must also be considered. Recovery has been attained in some 
cases of serous meningitis following otitis media by puncture of the ventri- 
cles (v. Beck and others). 

HYDROCEPHALUS 

Hydrocephalus is an accumulation of fluid in the cerebral ventricles and 
in the lymph spaces of the brain which, as a rule, leads to ventricular dilata- 
tion. In b} r far the majority of cases we have to do with a hydrocephalus inter- 
nus; at other times there is an effusion into the subarachnoid space, a hydro- 
cephalus externus. A further differentiation is made between congenital and 
acquired hydrocephalus, but while this distinction is possible from an anatom- 
ical standpoint it is impracticable clinically, since we can never determine 
whether a child who develops a gradually increasing hydrocephalus in the first 



HYDROCEPHALUS 531 

years of life did not have a small hydrocephalic effusion very soon after birth, 
therefore congenital. The intrauterine development of congenital hydroceph- 
alus occurs some time following the formation of the bones of the skull, there- 
fore after the seventh fetal month (Huguenin). The causes of hydrocephalus 
are varied. They may be sought within or without the chambers of the brain. 
The extra-ventricular sources depend upon circulatory disturbances in the 
venous sinuses and in the large vein of Galen and its collateral branches in 
which the venous return is hindered. The causes of hydrocephalus which are 
produced within the ventricles are of different nature. It is obvious that an 
inflammation of the ependyma gives rise to a decided accumulation of fluid in 
the ventricles. The starting-point of the effusion may be sought most fre- 
quently in an inflammation of the choroid plexus. This alone may cause an 
effusion in the ventricles of the brain, or it may be combined with the most 
diverse lesions of the cerebrum. 

In how far the ependyma of the ventricles plays a role in the development' 
of internal hydrocephalus is unknown. In quite a number of cases which have 
been described under the term " essential " hydrocephalus, in which therefore 
the cause was undetermined, no corroborative evidence for the pathogenesis 
could be found at the autopsy. 

Hereditary conditions have a special influence, and among these particu- 
larly the numerous nervous affections such as epilepsy, mental disease of the 
parents, also organic cerebral disturbances which have been brought into rela- 
tion with hydrocephalus. Tuberculosis, syphilis of the parents, alcoholism, 
conception while under the influence of liquor ( Bourne ville), parental care 
and sorrow, trauma or profound emotional conditions during pregnancy, are 
also mentioned as etiologic factors in congenital hydrocephalus. lEarriage of 
blood relatives, as well as a disproportion in the ages of the parents are said to 
have a bearing on the disease. After all, we can only deduce that congenital 
hydrocephalus has succeeded all of the conditions just mentioned, not that they 
are the actual progenitors of the affection. 

The pathogenesis of hydrocephalus which occurs in hereditary syphilis may 
be referred to very different causes. Frequently there are congenital cerebral 
anomalies which are associated with degenerative and distrophic processes in 
the brain substance : in other cases there are specific syphilitic affections which 
involve the ependyma, the cerebral membranes, the walls of the vessels, or the 
brain substance (L. D'Astros ) . 

Inhibitive processes and deformities of the cerebrum and even of the cere- 
bellum are often the cause of hydrocephalus, while the remainder of the 
nervous system may be normal. Other deformities are often associated with 
these malformations of the brain, such as cleft palate, bilateral club-foot, pes 
equino-varus, ectopia of the testicles or of the rectum, and closure of the anus. 
Spina bifida is sometimes present and may be complicated with meningocele or 
myelo-meningocele. 

Congenital hydrocephalus may develop intrauterine in consequence of de- 
formities of the brain without any post partum symptoms which would indicate 



532 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

the presence of the disease ; in other cases the malady arises from disease of the 
fetal brain of which the cause is unknown or can only be suspected. 

Thus far no phenomenon indicative of an intrauterine development of 
hydrocephalus has been discovered, and the pregnancy differs in no wise from 
the normal. 

Hydrocephalus may show itself after birth in the following forms. At 
times there is abnormal enlargement of the head or perhaps unusual small- 
ness (microcephalia). Again, the head may at first be of normal dimen- 
sions and enlargement occurs later. Acquired chronic hydrocephalus some- 
times develops soon after birth, in other cases it is latent. It may arise 
while the fontanelles and sutures are open or after the skull has closed. In 
the newborn there are certain primary infectious diseases, particularly of the 
gastrointestinal tract, that have a bearing on the development of the malady. 
Then there arises thrombosis of the venous sinuses in the skull (Marfan), 
or inflammation of the ependyma of the ventricles and of the meninges, or 
inflammation of the choroid plexus, which are associated with a profuse 
exudation of serous fluid. In other cases there are nutritive and circulatory 
disturbances of the most varied acute and chronic diseases of the brain, or 
hydremia which produces an increase of the exudation of cerebrospinal fluid. 
Occasionally in cerebral sclerosis there is an enormous effusion of fluid (hydro- 
cephalus ex vacuo) in the ventricles, or hydrocephalus follows a distribution 
of the sclerosis to the ventricular walls, with an implication of the choroid 
plexus. The ventricle in the hemisphere which is the seat of sclerosis is more 
markedly dilated than the other. 

Hydrocephalus may also arise from restricted circulation of the cerebro- 
spinal fluid due to inflammatory processes, i. e., closure of the foramen of 
Monro causes a dilatation of the lateral ventricle and an accumulation of 
fluid, closure of the aqueduct of Sylvius gives rise to stasis in the second 
and third ventricles, and closure of the foramen of Magendi produces an 
accumulation of fluid in all of the ventricles. Further, hydrocephalus may 
develop in the course of serous meningitis and even after cerebrospinal menin- 
gitis by inflammatory changes in the plexus or in the ependyma, or by an 
occlusion of the basal lymph channels brought about by inflammation. Cir- 
culatory disturbances which give origin to hydrocephalus are caused by tumors 
upon the side of the neck and in the mediastinum which hinder the return 
of the venous blood from the head, and also by tumors of the brain. The 
latter are referred principally to the base of the brain, to the posterior cranial 
fossa, and especially to the cerebellum. Hydrocephalus ma} r further arise 
from compression of adjacent venous trunks or of the vena magna Galeni at 
the side of the tumor, or from compression of the sinus by the dura mater 
(L. d* Astros, Barrier). 

In this form of hydrocephalus the abnormal effusion of fluid leads to 
decided enlargement of the skull, and the cranial sutures which have been 
firmly closed may be separated even in children from seven to twelve years 
of age (Barthez, Rilliet, Bourneville). Hydrocephalus may last for months 



HYDROCEPHALUS 533 

and even years with a sudden termination in coma or convulsions and 
death. 

Eickets is also mentioned in the pathogenesis of hydrocephalus (Pott). 
There is, however, by no means a specific condition dependent upon rachitis, 
but in the rachitic skull, in the ununited sutures, and in the softness of the 
bones there is sufficient stasis of the lesser circulation, such as occurs in pul- 
monary and cardiac affections, in the marked paroxysms of whooping-cough, 
in compression of the veins of the neck by tumors, etc., to produce decided 
exudation in the ventricles. Therefore these conditions are complications 
which occur in rickets. As a rule the ventricles are not at all or only mod- 
erately dilated in rickets; a decided ventricular effusion is relatively rare. 
On the contrary the enlargement of the rachitic skull may usually be referred 
to a hypertrophy of the brain or in some cases to a thickening of the cranial 
bones. The open fontanelles, their late closure, is due more to an enlarge- 
ment of the cerebral mass than to a hydrocephalic effusion (L. d* Astros). 

Meningeal or external hydrocephalus is much more rare than ventricular 
effusion. The former, as a rule, is of pachymeningitic origin, being due to 
pachymeningitis hemorrhagica interna between the layers of the arachnoid 
brought about by the transformation of a hematoma into a sac containing a 
more or less clear fluid, sometimes sanguinolent. In what manner the 
transformation of the hemorrhagic into a serous effusion occurs cannot be 
explained. 

Acute hydrocephalus occurs preeminently in nurslings and in the first 
years of life. At the onset of the disease a clinical differentiation of acute 
hydrocephalus from other acute cerebral affections is often impossible. 

The condition usually arises in the course of infectious diseases, especially 
of infectious gastrointestinal catarrh in nurslings. Eestlessness, gritting of the 
teeth, irregularity of the pulse, uneven respiration, spasm of the glottis, stra- 
bismus, pupillary inequality, and stupor are observed in the course of the affec- 
tion. Tonic and clonic convulsions suddenly appear, the fontanelles become 
prominent, and cerebral pulsations can be felt. Sometimes the bone separates 
and the circumference of the head increases. Coma gradually appears, the 
pupils dilate and fail to react, the glance is rigid and the patient perishes. 
Acute hydrocephalus may be replaced by the subacute or the chronic form. 

When meningeal hemorrhage from the onset is associated with convulsions 
and occasional fever, and is combined with contractures in the extremities 
(Legendre), there may be confusion with acute hydrocephalus. 

At the beginning of the disease there are no definite symptoms to indi- 
cate an acute effusion into the cerebral chambers. The condition of the fon- 
tanelles and of the sutures gives no support for the occurrence of an effusion 
in the course of the affection. Edema of the pia mater or of the cerebral 
substance may produce the same sj-mptoms, such as headache, sopor, con- 
vulsions, and coma, as are found in serous exudation in the ventricles. Ven- 
tricular serous effusion such as is observed in tuberculous meningitis, in 
rickets, and also in Bright's disease, will not be considered in this connection 



534 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

since in all of these affections there is but a single symptom — effusion into 
the ventricles — not the characteristic pathologic picture that is common to 
hydrocephalus. 

Symptoms. — The most important and decisive phenomenon is enlargement 
of the skull. Hydrocephalus is due to an accumulation of intracranial fluid. 
The enlargement is more marked the earlier the exudation begins, therefore 
when it develops intrauterine, and it may then become so great that birth is 
impossible unless the skull is perforated. Immediately following birth the 
head is more or less spherical; later, after some of the sutures have ossified 
and closed, while others are still capable of distension, there is a certain 
degree of asymmetry. As a rule the fluid is clear, light colored, and serous. 
In most cases there is an effusion into the cerebral ventricles; this may, 
however, enter the subarachnoid space and produce an external hydrocephalus. 
Attention is first drawn to the condition by the abnormally rapid and pro- 
gressive enlargement of the skull, but these cranial changes may now and 
then be preceded by repeated convulsions and contractures in the muscles of 
the extremities. These symptoms cannot primarily be utilized in diagnosis, 
therefore the increasing enlargement of the skull must be the determining 
factor and is dependent upon the degree of cranial distension and the amount 
of the fluid effusion. The circumference of the skull may be 60 to 90 cm. 
Palpation readily demonstrates the broad sutures and enlarged fontanelles; 
the latter are prominent and distinctly fluctuate. The skull also shows 
retarded ossification and in occasional extreme cases of hydrocephalus dis- 
seminated bone nuclei may be felt in the tense and fluctuating membranes 
which unite the cranial bones. The enlarged head with its abnormally wide 
sutures, tense membranes, and thin bone, may be so transparent that the 
light of a burning candle, or sunlight, can be seen through the skull. The 
veins of the head are often dilated and the hair is scant and of slow growth. 
The prominence of the frontal bone is in marked contrast with the thin, 
triangular face. The frontal bone is arched anteriorly, the occipital bone 
posteriorly, the parietal and temporal bones are forced aside. 

The supraorbital plate is flattened, the bulbi are often protruded and 
forced downward so that the white upper scleral border is visible and the 
lower scleral margin obscured, and about one-half of the iris is covered by 
the lower eyelid. In consequence of the enormous increase in volume the 
head cannot be held upright without support but wobbles to and fro, fol- 
lowing the law of gravity. 

Nutrition is often poor ; the temperature is normal ; dentition is retarded. 

The nervous symptoms are of the most varied character and may arise 
at the onset or during the course of the affection. Often they reappear after 
certain intervals; their frequent recurrence as a rule indicates exacerbation 
of the disease. The nervous phenomena are dependent upon congestion or 
upon an increase of the intracranial pressure. After the pressure has become 
stationary and the brain has accommodated itself to this pressure all the 
symptoms may disappear. 



HYDROCEPHALUS 535 

At the onset of the affection there is sometimes headache, restless sleep, 
often there are sudden outcries. Mental development is retarded, the child 
for the most part is apathetic, occasionally disagreeable, does not appear to 
see and hear distinctly, and fails to recognize those about him. Memory 
suffers. Speech is incomplete, hesitating, slow, the child lalls, now and then 
speaks indistinct words, and not infrequently presents the picture of com- 
plete idiocy. The mental condition is not dependent so much upon the hydro- 
cephalic effusion as upon the concomitant cerebral disturbance (Bourneville). 

Movement of the upper extremities is not, as a rule, greatly affected, but 
there may be uncertain movements resembling chorea, particularly when the 
child attempts to grasp an object. In the lower extremities however there 
is almost always a distinct weakness and when an attempt is made to place 
the child on its feet the legs are crossed or raised. The gait is hindered, 
difficult, waddling; debility may be so great that the legs cannot support the 
body, or if there is a large effusion complete paralysis develops. Unilateral 
paralysis is extremely rare. Naturally there are also cases in which this 
weakness of the legs is insignificant. 

From the onset of the disease until the terminal stage there are various 
contractions in the arms, legs, and face ; spasm of the glottis, strabismus, and 
nystagmus are observed, and often paralytic phenomena on the part of the 
oculomotor and abducens nerves to which actual eclamptic attacks are added. 
In addition there is transitory somnolence, involuntary voidance of feces and 
urine in the bed, and decrease or loss of sensation. Ophthalmoscopic exam- 
ination frequently reveals choked disc or pressure atrophy of the papilla nervi 
optici. There may be total blindness. Contractures sometimes develop in 
the course of chronic hydrocephalus which at first are slight. Usually the 
fingers are first involved, then the forearm and the lower leg, and finally 
the muscles of the trunk. 

Hearing is not always intact, but the sensations of taste and smell undergo 
no demonstrable change. 

Respiration, circulation and digestion may remain normal for } r ears, but as 
a rule there is emaciation, the skin becomes pallid and wrinkled, the muscles 
are atrophic, and the child is so weak that it cannot stand, must recline in bed, 
and cannot support the head but rolls it from side to side upon the pillow. 
With the increasing weakness there are symptoms on the part of the lungs and 
heart such as atelectasis and broncho-pneumonia associated with cyanosis and 
dyspnea, or cardiac asthenia, which threaten the life of the patient. 

The course is often progressive, sometimes there is sudden exacerbation 
of the process which is indicated by severe headache, spasm, general convul- 
sions, and paralytic phenomena, occasionally associated with febrile symptoms, 
all of which are dependent upon cerebral congestive conditions. 

Nervous symptoms occasionally appear even before enlargement of the 
skull, such as spastic muscular contractures in all of the extremities (v. 
Ranke, Ganghofner), and repeated convulsions have been known to precede 
the changes visible in the skull. 



536 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

Many children die in the course of a few months or in the first years of 
life. Death sometimes results from an eclamptic attack; in other cases the 
emaciated patient succumbs from debility, or intercurrent diseases hasten the 
lethal outcome. 

Only exceptionally is there an arrest of the process; the skull hardens 
and closes and the patient may reach an advanced age, but mental develop- 
ment is retarded. Two hydrocephalic patients, the circumference of whose 
skull measured 86 and 88J cm. (L. d ? Astros), attained an age respectively 
of 29 and 60 years. 

It must, however, be remarked that exceptionally a child with a hydro- 
cephalic skull, who in the first years of life frequently suffered from eclamp- 
sia, was retarded mentally, could scarcely lall, much less speak, and in whom 
there was a paralysis of the lower extremities with alternating contractures^ 
has begun between the sixth and tenth years to develop mentally as well as 
physically, so that in the course of time nothing remained of the early severe 
symptoms. The symptom which is relatively most protracted is that of weak- 
ness in the lower extremities, but even this may disappear under the influ- 
ence of a proper stimulating diet, the use of brine baths, massage, and elec- 
tricity. The prognosis, therefore, is not absolutely hopeless throughout. 

Recovery from chronic lrydrocephalus may exceptionally follow spontaneous 
rupture of the hydrocephalic effusion through the nose, the ears, the cavity of 
the eye, or by traumatic influences which implicate the skull. With decrease 
of the effusion, and with good nutrition, the brain may develop, the bones of 
the skull grow stronger and fill the space of the discharged fluid, the sutures 
and fontanelles may close. Nevertheless this form of recovery must be con- 
sidered hypothetically. 

Pathology. — The anatomical finding reveals general enlargement of the 
skull and smallness of the facial bones. The head is spherical, the supra- 
orbital plate is flattened, the ethmoid bone depressed, the transverse diameter 
is greater than the sagittal measurement. The brachycephalia is more prom- 
inent the younger the individual, and is dependent upon the effusion of fluid. 
If the patient recovers, the peculiar shape of the skull is often noticeable 
in advanced age. The quantity of fluid varies from 300 to 500 c.c, and often 
amounts to a quart or more. Remarkably large fluid accumulations have 
been reported, for example in Esquirol's case, where the fluid measured 36 
quarts (L. d'Astros). The composition is that of normal cerebrospinal fluid. 
In chronic cases it is clear and colorless, or faintly tinged with green. The 
reaction is alkaline, the specific gravity ranges from 1.001 to 1.009. It con- 
tains a trace of albumin, 0.5-1.3 to 1000 c.c, and in addition 5 to 8 grams 
of sodium chlorid. The relation of the ventricular effusion to effusion in the 
subarachnoid space varies. Communication of the fourth ventricle with the 
posterior subarachnoid space through the foramen of Magendi is not always 
present, especially in the first year of life (L. d'Astros). The inconstancy 
of this communication is of great importance from the standpoint of eventual 
surgical intervention. 



HYDROCEPHALUS 537 

Dilatation of the ventricle is the natural result of the effusion of fluid 
and shows extraordinary modifications. It may be so marked that upon 
removal of the top of the skull the brain protrudes like two bladders, and, 
after it is cut, the layers, thin as paper, permit the soft cerebral substance 
to collapse. The effusion is frequently distributed uniformly to both lateral 
ventricles, but It may be greater on one side than the other, or in one pos- 
terior horn than in the other. The foramen of Monro is enlarged, sometimes 
to 3 or 4 cm. in diameter. The third ventricle is dilated, sometimes also 
the aqueduct of Sylvius and thereby the fourth ventricle. The distension 
of the skull may be uniform, or premature and partial synostosis may cause 
more or less asymmetry. The sutures of the skull are wide, the fontanelles 
are uncommonly large, and the frontal fontanelle often extends to the root 
of the nose. The cranial bones are thin, flexible, transparent and glistening. 
Ossification of these bones, if it occurs at all, requires many years for its 
completion, partly because of the outgrowth of long serrated processes on the 
border of the bone, partly because of the development of new points of ossi- 
fication within the sutures and fontanelles — the so-called Wormian bones 
(Virchow). Under the influence of the effusion the brain substance is 
reduced, sometimes from 2 or 3 cm. to a few millimeters, the gyri are sepa- 
rated, and the furrows obliterated. The brain is flattened at the base, soft, 
and atrophic; the cerebellum is frequently atrophic or may be altogether 
absent, in other cases it appears asymmetric or hypertrophied (Chiari). In 
marked hydrocephalus the hypertrophic cerebellum may be pressed down into 
the vertebral canal and resemble a cervical spina bifida, although it is in fact 
an encephalocele. In the walls of the ventricles, in the meninges, and in the 
plexus the most manifold changes occur, such as thickenings, granulations, or 
net-like proliferations, which are of inflammatory origin. The cerebral nerves 
are often atrophic, and in some few cases are absent. 

The spinal cord is usually intact. Nevertheless hydromyelia of various 
grades has been observed (Chiari). 

In acquired hydrocephalus the effusion and the disappearance of the cere- 
bral substance are usually not so marked. 

In external hydrocephalus there is pachymeningitis — an inflammatory 
process with extravasation of blood upon the inner surface of the dura mater 
which runs its course without any definite symptom-complex during life that 
would denote such a condition (Henoch). 

Treatment. — Chronic hydrocephalus with extensive enlargement of the 
skull is incurable. The administration of calomel, and layers of adhesive 
plaster or narrow bandages around the head to produce a uniform compres- 
sion are useless. Vesicants, inunctions with tartar emetic ointment, unguen- 
tum veratrinae, croton oil or mercurial ointment, are all ineffective. Specific 
treatment may be instituted in hydrocephalus dependent upon syphilis even 
though there be but a faint suspicion of infection. Nevertheless, the result 
of this treatment is often doubtful. 

Surgical treatment has thus far given such poor results that upon the 



538 MENINGITIS OF INFANCY, AND HYDROCEPHALUS 

whole operative interference is not often advisable. Certainly in the greater 
number of cases of congenital hydrocephalus we cannot expect that normal 
conditions for the development of the brain will be furnished by the with- 
drawal of fluid. In the quiescent form nothing is to be expected of surgery. 
In mild cases this treatment may be attempted. When the accumulation of 
fluid is progressive and the intracranial pressure increases, when life is threat- 
ened and functional cerebral disturbances arise, the sight suffers and severe 
headache appears, an operation is indicated. We must then consider lumbar 
puncture or puncture of the skull. Quincke's method involves the patient in 
least danger. In a great many cases the procedure is unsuccessful, and nat- 
urally there can be no result if no communication exists between the ven- 
tricles and the subarachnoid space. Nevertheless, an exploratory puncture 
should be made. Quincke inserts the needle between the third and fourth 
lumbar vertebras, Chipault between the last lumbar vertebra and the sacrum. 
The patient is placed in the lateral posture with back Bent forward and legs 
flexed. In a child the needle may be introduced directly between the spinous 
processes and conducted to a depth of 2 or 3 cm. toward the arachnoid space 
in the median line. The fluid is permitted to ooze slowly and only a small 
quantity is withdrawn at one operation. Large amounts are prohibited, since 
death may result from sudden relief of the brain. Therefore if spina bifida 
exists simultaneously the latter should not be punctured, otherwise we must 
expect a continual flow of cerebrospinal fluid which no known methods can 
control, and the patient perishes more rapidly than if puncture were not 
performed. After the needle is withdrawn, a dressing of iodoform collodion 
is applied at the point of puncture. 

Exceptionally a cure has been attained by puncture (Schilling), or some- 
times a transitory benefit is noted ; but in most cases there is no improvement. 
Some authors advise direct puncture of the ventricles and have reported 
favorable results (v. Beck, Schilling, Graefe). The puncture must be per- 
formed with a fine capillary trocar and in the median line if the fontanelle 
is sufficiently broad, otherwise the insertion is made in its lateral angle. Only 
a small quantity of fluid should be allowed to escape. Puncture with suc- 
ceeding injection of iodin has not been reported favorably except by Tour- 
nesco, and must at present be rejected (Monti, Eanke and L. d'Astros). 

The dangers of ventricular puncture and its subsequent drainage are very 
great and the majority of patients perish in a few hours. 

Somma advises direct sunlight upon the head daily for thirty to fifty 
minutes. If the patient is mentally deficient treatment must be continued 
in a suitable institution. 

Acute hydrocephalus requires a purely symptomatic treatment suited to the 
underlying affection. 

[Chronic hydrocephalus depending on rachitis of the cranium — cranio- 
tabes — is not so desperate. Many cases get well. It appears that the effusion 
is absorbed and brain substance may take its place. Big-headed rachitic 
children are frequently the best scholars in after life. — Editor.] 



INFANTILE SPINAL AND CEREBRAL 
PARALYSES 

By A. Hoffa, Wurzburg 

While the general picture of infantile spinal paralysis is well known and 
familiar to physicians, this is not the case with infantile cerebral paralysis, for 
we have gained our minute knowledge of the latter condition only in the last 
decades. Still generally unknown is the fact that cerebral paralysis is very 
amenable to treatment, and that quite remarkable results may be attained in 
cases which were formerly regarded as incurable. Further, the pathologic 
picture of each is often confused with the other in that spastic paralysis has 
been considered a special form of spinal paralysis. 

A sketch of both diseases is therefore indicated, and later a description of 
the differential diagnosis. Finally, a discussion of their treatment will reveal 
what may be accomplished by a proper therapy. 



INFANTILE SPINAL PARALYSIS 

In the 3 r ear 1840 S. v. Heine directed the attention of the profession to a 
definite, well-characterized, and common form of paralysis in children, to 
which he gave the name infantile essential paralysis. Later (1860) he con- 
cluded that this paralysis was a disease of the spinal cord. The first actual 
confirmation of this theory was attained only recently by Prevost and Vulpian, 
Charcot, Gofiroy, Eoger, Money, Kussmaul, Strumpell, and others, so that 
now, instead of the word " essential," we quite properly use the term infantile 
spinal paralysis. 

The disease occurs almost exclusively in children between the first and 
fourth years. According to my statistics the proportion is 1.3 to every 1000 
surgical cases; in every 1000 deformities 67 are unquestioned spinal paralysis. 

Pathology. — The anatomical origin of the disease is an acute inflammation 
which implicates a definite area of the anterior gray substance of the spinal 
cord. The usual lesion which is found at autopsy in cases of long standing is 
a decided atrophy of the anterior horn, which is changed into coarse sclerotic 
tissue, often permeated by dilated and thickened vessels, and which contains 
scarcely any normal ganglion cells. From the primary focus of the disease a 
secondary degeneration develops and distributes itself toward the periphery, 
implicating the corresponding anterior roots, the motor nerves belonging to 

539 



540 INFANTILE SPINAL AND CEREBRAL PARALYSES 

them, and the muscles supplied by the latter. Therefore, in the paralyzed 
muscles and nerves we find a high-graded degenerative atrophy. 

Symptoms. — The disease almost always begins suddenly and attacks previ- 
ously entirely healthy and sound children. The initial symptoms are high fever, 
headache, pain in the back and in the limbs, mental confusion or complete loss 
of consciousness, accompanied by local or even general convulsions, all of which 
usually disappear rapidly. After the conclusion of this first stage there is a 
more or less well-distributed paralysis. Both legs, or the legs and an arm, or 
all four extremities, and perhaps also the muscles of the trunk are implicated. 
This extensive paralysis is not persistent. On the contrary, it shows rapid 
regression and localizes itself in that region which is permanently paralyzed. 
In 7 out of every 10 cases only one limb is involved, usually the left leg; next 
in order of frequency is paralysis of both legs. Paralysis of all the extremities 
or of both arms, as well as simple and crossed hemiplegias, are rare. In the 
great majority of cases the extensors are paralyzed. 

While the general condition of the children improves, the paralysis which 
remains is exclusively flaccid and atrophic. A few weeks after the onset of the 
malady the affected muscles show distinct atrophy which gradually increases to 
an extreme degree. Occasionally it is concealed by a marked development of 
fatty tissue. Even more rapid than the apparent atrophy are the changes in 
electric contractility of the paralyzed muscles. There is a well-developed reac- 
tion of degeneration (DeR). Very frequently the growth of the affected ex- 
tremity is retarded so that later the bones shoiv a shortening of several centime- 
ters. However, as was shown by Yolkmann, there is not always a parallelism 
between the muscular atrophy and the inhibited growth. The tendon and cuta- 
neous reflexes are almost always absent. Cutaneous trophic disturbances are 
common; the skin is cool and often lias a cyanotic appearance; sensation, how- 
ever, is completely retained. Bladder and rectum are seldom paralyzed. A 
further result of this muscle and nerve paralysis is the paralytic contracture, 
to which we must now direct our attention. 

For the proper understanding of these paralytic contractures a physiologic 
description of the antagonism of muscles is absolutely necessary. Following 
Riedel, this may be best accomplished by study of a normal muscle, the tendon 
of which has been severed. 

When a tendon is cut or is separated from its osseous support the elasticity 
of the muscle causes a permanent retraction. The muscle flies back like a 
piece of India rubber which has been made taut and then cut. As the inter- 
muscular connective tissues do not contain coarse and especially elastic fibers 
the detached muscle may remain outstretched for some time, but eventually it 
contracts constantly more and more until it can no longer be extended. The 
muscular substance, however, for a long time remains unchanged, at least mac- 
roscopically ; but it finally presents the typical picture of myositis fibrosa. 

In the antagonists of the severed muscle the condition is different. At the 
moment when the tendon is separated the antagonist contracts. Simultane- 
ously it contracts in consequence of its elasticity and remains shortened perm a- 



INFANTILE SPINAL PARALYSIS 541 

nently because it is not capable of extension actively beyond the measure of its 
relaxation; it does not, however, contract like the muscle which has been sev- 
ered in its continuity, because it is capable of extension passively and involun- 
tarily. If, for example, the flexor tendon of a fmger is separated, the finger 
assumes the position of extension. This, however, will be altered involuntarily 
because of conjoint action in carrying out movements with the other fingers, 
as well as passively in the sense of finger flexion, as it is impossible to keep a 
permanently extended finger in constant repose. If the hand were not used at 
all the antagonist would atrophy from disuse. This condition affects the 
antagonists of the foot much more frequently than those of the hand because 
the action of the toes is less than of the fingers, particularly if other injury 
demands rest of the foot. After extensive tears of tendons on the dorsum of 
the foot we occasionally note marked atrophy of the flexors of the toes, so that 
the latter present complete distortion and fixation. Careful tenotomy of a 
portion of the extensor tendons does not usually produce this contraction, be- 
cause the affected toe is implicated too much in the movements of the others 
(Eiedel). 

Furthermore, the elastically retracted antagonist retains the property of 
contraction under the impulse of the will, and the repeated contraction and 
relaxation thereby occurring may prevent atrophy, although naturally the 
effect of the contraction cannot be very great. 

The elastic retraction of the antagonist overcomes great resistance, even 
that of gravity. This may be recognized in a transverse separation of the 
radial nerve high on the upper arm. Such an injury may be said to be analo- 
gous to separation of tendons, for it has the same effect on the muscle, the 
action of the completely paralyzed muscle being quite similar to that of the 
severed tendon. 

In such an injury to the radial nerve we note at once that the hand as- 
sumes a permanent flexure immaterial whether the forearm is pronated or 
supinated. The hand remains supine even in opposition to gravity. 

We may now return to the consideration of the paralyzed muscle. 

From what has been stated it is evident that the completely paralyzed mus- 
cle will shorten in consequence of its inherent elasticity. 

This elasticity is, however, by no means identical with what was formerly 
designated as muscle tonus. By this was understood a constant, weak, involun- 
tary contraction of the muscle, dependent upon the nervous system, and, since 
Delpech's promulgation of the antagonistic theory up to recent times, all para- 
lytic contractures were explained by this tonus, in that the non-paralyzed 
antagonists were able by virtue of their tonus to draw the affected extremity 
to their side. 

This theory of muscle tonus, which did not exist physiologically, was 
opposed by Werner in 1851 and has been entirely rejected since the researches 
of Hueter and v. Volkmann. These two authors deduced their observations 
from infantile spinal paralysis. They referred the deformities which exist 
in this disease principally to mechanical influences by demonstrating that 



542 INFANTILE SPINAL AND CEREBRAL PARALYSES 

particularly the weight and the implication of the 'paralyzed member come 
under consideration. , They, however, proceeded one step too far by entirely 
disregarding the contraction and elasticity of the paralyzed muscle. The credit 
of reinstatement and correct explanation of these factors belongs to Seelig- 
miiller, and subsequently to Karewski, Lorenz, and Kiedel. 

Following Seeligmiiller we now designate this hypothesis of the develop- 
ment of paralytic contractures, which will now be detailed, the antagonistic- 
median leal theory. 

In all paralyses wherein some of the muscles which control a joint are 
exclusively or predominantly paralyzed, the impulse of the will for voluntary 
attempts at movement, arising in the brain, can only reach those muscles to 
which the nerve conduction has remained intact. Accordingly, the non-para- 
lyzed antagonists will contract and give to the member a definite position. The 
joint must remain in this position because the paralyzed muscles have not the 
power to stretch the voluntarily shortened antagonists, which, however, in con- 
sequence of their elasticity are already permanently contracted. Each new 
impulse of the will must follow the same course. This may finally cause such a 
high-graded contraction that the contractures arising therefrom will overcome 
gravity. Thus, in paralysis of the flexors of the leg, the intact quadriceps 
femoris, in opposition to gravity, occasionally produces a genu recurvatum, 
while in paralysis of the plantar flexors the extensors of the foot produce a pes 
calcaneus. 

We just remarked that the contraction " may " assume an extreme degree. 
The word may was used with intent because there are cases in which contrac- 
tion does not occur notwithstanding the fact that numerous impulses of the 
will constantly take the same road. In these cases, as a rule, the affected mem- 
ber has received much passive motion from the onset. Probably there is also 
a special central predisposition to contraction which may not infrequently be 
recognized by a tendency to edema in the paralyzed part. 

In any event we cannot contest the statement that the paralytic contrac- 
tures are primarily due to voluntary contraction — not the tonus ! — of the non- 
paralyzed antagonists. The final position, however, depends upon still other 
factors : the individual gravity of the member and its implication by the body 
weight, therefore upon mechanical factors. From the moment of paralysis the 
struggle of these agents with the unaffected muscles begins. 

Which of the two is victor in this battle, or how they are united in their 
deleterious action, will now be investigated. 

Our starting-point must be from the supposition that not a portion but 
all of the muscles which control a joint are completely paralyzed. Under such 
circumstances the muscles are flaccid and weak and a loose joint may de- 
velop provided no other mechanical influence has arisen. In the latter case, 
contractures may result. These can only be governed by the conduct of mechan- 
ical forces, and therefore will always assume the shape which is given to the 
member by the gravity of its individual parts and their implication, i. e., the 
position in bed or with bandages applied. 



INFANTILE SPINAL PARALYSIS 543 

If the paralysis is uniformly distributed to all of the muscles of the joint, but 
is not complete, so that a portion of the muscular function is retained, the 
action of gravity and the use of the paralyzed limb in walking, standing, slid- 
ing, grasping, etc., will unite to produce the deformity. For the further devel- 
opment of contracture another factor must be considered, namely, the greater 
power of the muscles of the flexor side of the joint than those of the extensor 
surface. This preponderance of the flexors over the extensors is generally rec- 
ognized and has been demonstrated anatomically by E. Fischer, histologically 
by Griitzner. It is for this reason that prolonged use of the affected joint will 
tire the extensors more readily than the flexors, so that the latter pull the 
member to their side. Therefore, in this condition flexor contractures are 
usual. 

If not all of the joint muscles are paralyzed, but only isolated muscles or 
muscle groups the antagonistic-mechanical theor}' of Seeligmiiller, which was 
explained above, will be admirably demonstrated. The contracture is intro- 
duced by the contraction and relaxation of the antagonists. The insertions of 
the latter, which have been approximated, are not drawn back into their pre- 
vious position, therefore their nutritive contraction follows, which, as already 
stated, may even overcome gravity. In general, however, the contracture is 
influenced by the gravity and weight of the joint in the following manner: 

First, the gravity and weight of the joint may act in the same sense as a 
beginning muscle contraction. The deformity will then become permanent 
all the more rapidly as the power to extend the points of origin and insertion 
of the shortened muscles is lessened. 

Consequently the distribution of the paralytic phenomena may exclude 
such a combined action; for example, the paralysis may predominantly impli- 
cate the flexors of the lower leg, and the influence of the weight of the foot 
may be arrested or decreased, for a time at least, by the active contraction of 
the extensor muscles. Xevertheless, in the majority of such cases the external 
forces gain the victory over the functionating muscles and only rarely do the 
latter have a decisive influence on the anomalous posture. 

It must be mentioned that the shortening of the muscles, once established, 
especially in growing individuals, is certainly augmented still further by 
tropho-neurotic changes. 

Torticollis Paralytica. — The individual paralytic deformities must now be 
briefly considered. Torticollis paralytica is the result of paralysis of the 
sternocleidomastoid muscles supplied by the spinal accessory nerve. The affec- 
tion is rare; I have seen it twice only. This paralytic wry-neck is character- 
ized by an abnormal position of the head, due to the preponderance of the 
normal muscles of the opposite side. The chin is raised and turned somewhat 
toward the diseased side. Voluntary rotation of the head is difficult, but may 
be accomplished passively. The power to turn the head is not entirely arrested, 
as this may be performed by uninvolved muscles. 

The absence of muscle prominence is characteristic, provided the move- 
ments produced by the sternocleidomastoid are executed with some slight re- 



544 INFANTILE SPINAL AND CEREBRAL PARALYSES 

sistance; for example, with the chin supported by the hand, the patient is 
asked to move it downward or sidewise, whereupon only the belly of the normal 
muscle of the sound side becomes prominent. A prolonged paralysis may cause 
complete contracture of the normal muscle and therefore a permanent inclina- 
tion of the head. 

I shall not detail the changes which occur in caput obstipum at the base 
of the skull, which may implicate symmetry and produce scoliotic curvature of 
the vertebral column. 

For the positive diagnosis of torticollis paralytica Boyer advises anesthet- 
ization. During narcosis the contracture of the antagonists is overcome and 
the head assumes its normal position. This applies, however, only to recent 
cases. In affections of long standing, wherein a nutritive shortening of the 
antagonists has occurred, it is impossible even during anesthesia, to relieve the 
deformity by torsion or pressure. In the diagnosis of torticollis paralytica 
the presence of other paralyses is to be considered, and important data may 
be gleaned from the history. 

Lordosis. — Among the curvatures of the spine which arise from anterior 
poliomyelitis we must first mention lordosis. This paralytic deformity may 
be due also to paralysis of the abdominal muscles, but particularly to paralysis 
of the long extensors of the back. If the abdominal muscles are paralyzed the 
patient is in danger of falling backward when he stands upright, as the long 
extensors of the back are not controlled by their antagonists upon the anterior 
surface of the body. The patient aids himself instinctively by causing both 
ileopsoas muscles to draw the lumbar portion of the spine strongly forward, 
and by a backward inclination of the upper trunk. Thus an extreme lordosis 
develops. If, on the other hand, the long extensors of the back are paralyzed, 
to prevent a fall forward the patient attempts to maintain his equilibrium by 
bending the upper trunk strongly backward. The body is then poised by the 
action of the abdominal muscles and its own gravity. The result again, how- 
ever, is marked lordosis of the lumbo-vertebral column, for here, as the most 
flexible portion of the spine, the backward movement naturally occurs. 

A characteristic feature of paralytic lordosis is that the curvature of the 
spine at once disappears when the patient is placed in the horizontal position. 
The vertebral column then closely approaches the horizontal plane. This form 
of lordosis is very rarely permanent. 

Further, curvatures of the spinal column which simulate lordosis are 
observed in marked flexor contractures of the hip-joint ; they are then the con- 
sequence of increased pelvic inclination. These cases will be considered in the 
description of paralytic contractures of the hip-joint. 

Paralytic scoliosis is a more common sequel of infantile spinal paralysis, 
particularly if one side of the back is paralyzed. Normal muscles will usually 
flex the vertebral column toward their side, so that a curvature of the spine 
arises. However, this may occur from purely static causes. If, for instance, 
in a paretic affection of the muscles of the back, the trunk is to be elevated, 
the patient instinctively attempts to hold the spinal column, which gives him 



INFANTILE SPINAL PARALYSIS 545 

the greatest support on account of the contact of the bones, and thereby 
various forms of curvature arise according to the degree of the paralysis. 

Paralytic scoliosis has not until lately been properly appreciated. Thor- 
ough work has been devoted to it by Moussarrat, Hallion, Messerer, Kirmisson, 
Sainton and Mirallie. The reports of these investigators show that the con- 
vexity of paralytic scoliosis was directed in the majority of instances (14 times 
in 17 cases) to the sound side. Only thrice was the convexity of the scoliosis 
toward the paralyzed side. 

It is characteristic of paralytic scoliosis that it becomes fixed either late or 
not at all, that only rarely is there pronounced curvature of the back, and that 
the axis rotation of the vertebra is not well marked. Consequently there is a 
difference in the electric contractility upon the diseased side which favors the 
normal muscles. 

Xot infrequently there is also an inhibited development of the thorax 
upon the paralyzed side which is responsible for a marked asymmetry of that 
structure. Messerer observed 8 cases of this kind, 7 of which showed the sco- 
liotic curvature in a direction opposed to the paralysis. In one case only were 
j^aralysis and scoliosis noted upon the same side. 

I have observed in my practice numerous cases of scoliosis as a sequel of 
infantile spinal paralysis. Here the scoliosis, which is only secondary, so to 
speak — the static form which is the sequel of the shortening of a leg or of a 
flexor contracture at the hip or knee — must be differentiated from actual para- 
lytic scoliosis, i. e., the scoliosis due to paralysis of the muscles of the back. I 
had 6 cases of the latter form. In 5 of these the convexity of the scoliosis was 
directed to the normal side, which is the rule; in the remaining case the con- 
vexity was on the paralyzed side. I explain the formation of a curvature on 
the same side as this right-sided paralysis by the fact that the patient showed 
a constant tendency to turn toward the diseased side after he found a point 
of support in the bones and had a firmer hold on the borders of the vertebrae. 
The bod}', therefore, in this case was able to overcome the pulling of the sound 
muscles. 

Passing to the shoulder, we must first consider the paralytic loose joint. 
The shoulder muscles, notably the deltoids and the outward rotators, are at the 
same time the tensors of the capsule of the shoulder-joint. Like the cartilagi- 
nous limbus in the hip- joint, they serve for the equilibrium of the arm in the 
shoulder. If these muscles lose their function by an anterior poliomyelitis, the 
tension of the capsule is relaxed, but the arm droops because of its weight, and 
draws the internal rotators as far downward as is permitted by the flaccid cap- 
sule. The weight of the arm plays constantly upon the atonic capsule and is 
thereby able to distend it considerably. This, however, destroys the function 
of the joint and a flail joint arises. Such a paralysis of the shoulder may 
occur without implication of the extremities. 

In paralysis of the shoulder the normal curve has been lost, the acromion is 
prominent, below the acromion there is a deep groove which passes into a 
gentle convex arch in the contour of the arm. This groove has arisen from 
36 



546 INFANTILE SPINAL AM) CEREBRAL PARALYSES 

the lowering of the arm, for the pressure of the air has forced inward the soft 
parts between the acromion and the head of the humerus. The arm hangs 
flaccidly upon the chest and is usually rotated somewhat inwardly, while the 
hand is in a position of marked pronation. This inward rotation of the arm 
with hyperpronation always occurs as soon as the action of the outward rotators 
has been lost, the movement of the upper arm then being subject principally to 
the action of the inward rotators, the pectoralis major, the latissimus dorsi and 
the teres major. The entire arm hangs in the flaccid capsule. The arm can be 
forced in the greatest excursus forward and backward, and may also be raised 
so high that the head of the bone reaches the plane of the joint, or may be 
forced so far anteriorly or posteriorly that there is at the borders an appear- 
ance of subluxation. As soon as the support of the arm is withdrawn it falls 
by its weight as far as the capsule permits and therefore presents a typical flail 
joint. 

Active elevation of the upper arm is impossible, for the patient can only 
move the shoulder-blade, which, in consequence of flaccidity of the capsule, has 
no notewortlry influence upon the movement of the arm. At most partial 
movements of the arm may be carried out with the aid of the muscles of the 
chest and back. By hyperpronation of the forearm the use of the hand is 
decidedly limited. 

The muscles not only appear by inspection to be feebly developed, but they 
are so in fact. Upon palpation, instead of the tense muscle we note below the 
skin only a soft, flaccid mass. The faradic contractility of the muscles is 
nsnally absent, while cutaneous sensation is retained. 

The paralytic shoulder deformity will not disappear of itself. On the con- 
trary, the condition increases constantly with the growth of the child. The 
distance of the head of the bone from the acromion, which at first may be only 
about 1 cm., increases more and more until finally it amounts to 3 cm. or over, 
and may be so great that three or four fingers can be placed in the interspace. 

In addition to the deformity, the muscular atrophy, and the helplessness 
of almost the entire upper extremity, in the further course there is a retarda- 
tion of the entire development of the affected side. The growth of bone is 
lessened in all of its dimensions, so that not only the upper arm but also the 
scapula and the clavicle are decidedly smaller in later life than those of the 
healthy side. The atrophy may also involve the entire upper half of the trunk. 

Another consequence of infantile spinal paralysis, in so far as it affects 
the shoulder, is the wing-like retraction of the shoulder-blades. This de- 
formity is due to paralysis of the larger serratus anticus. The affection may 
also be the only remaining sequel of an extensive paralysis. The diagnosis 
is clear, for not only is the position of the shoulder-blade perceptible, but the 
anterior surface of the bone may be easily palpated. 

Anomalous positions of the elbow- joint due to muscle contractures are as 
infrequent as those of the shoulder. Both are opposed to contractures by the 
weight of the hanging limb as well as the many voluntary and involuntary 
movements in the extremity, which is entirely free of pain. The conditions 



INFANTILE SPINAL PARALYSIS 547 

are somewhat different in the hand, where the comparatively weightless fin- 
gers react more readily to the traction of contracting muscles. However, 
even here, on account of the frequent movement of the joint, a rigid con- 
tracture is unusual and appears only late. Seeligmiiller saw flexion rigidity, 
that is, extension contracture, 5 times. In the explanation of contractures 
we must always bear in mind that these will arise only when a perma- 
nent approximation of the points of insertion and origin of the muscle has 
occurred. 

We will now describe paralytic contracture of the fingers — a rare sequel 
of infantile spinal paralysis. As a rule the paralyzed hand is flexed, while 
the forearm is pronated. Exceptionally different conditions may prevail, 
especially if there are external mechanical influences. Thus, in a patient who 
for years carried his hand in a sling, with the elbow-joint in a right angle, 
there was pure ulnar flexion. If the paralysis has affected the radial nerve 
alone, the hand hangs flaccid, can never be raised, and even dorsal flexion 
is impossible. If an attempt is made to voluntarily extend the flexed fingers 
there will be only a partial extension, which is accomplished by the action of 
the interossei and lumbricales, i. e., with an existing flexion of the basal 
phalanges only the middle and nail phalanges are extended. 

If the ulnar nerve only is involved, the " claw-hand " develops. At the 
onset of the paralysis ulnar flexion and abduction of the hand and flexion of 
the last three fingers are arrested. Later the inhibition of the last movement 
leads to the characteristic partial extension contracture, with conspicuous 
atrophy of the soft parts in the interosseous spaces. The deformity is always 
most marked in the third and fourth fingers, but the other fingers are also 
gradually involved. 

Paralysis of the median nerve is characterized by immovability of the 
second and third phalanges in the index and middle fingers, arrest of flexion, 
and opposition of the thumb. The flexion of the first phalanges of the four 
fingers is unhindered on account of the action of the interossei. 

At the hip-joint, as in the shoulder-joint, after infantile spinal paralysis 
we find a loose socket, which has arisen from paralysis of all of the muscles 
surrounding the hip- joint, v. Tolkmann has given a very concise descrip- 
tion of this flaccidity : " This does not lead to a hyperextension from gradual 
stretching of the anterior capsular wall. Although the strongest ligament 
in the human body, the ligamentum Bertini, is located here, nevertheless it 
gradually relaxes when the patient allows the full weight of the body to exert 
it continuously. This is brought about by letting the pelvis sag as far as this 
ligament permits instead of supporting it. The region of the symphysis 
pubis then appears to be markedly extended and the curvature of the lumbo- 
vertebral column is increased anteriorly. Young children in particular 
assume a position which greatly resembles congenital dislocation of the 
hip-joint." 

Loose joints of this kind I have treated 5 times. In these cases the soft 
parts around the joint were almost completely atrophied and the head of the 



548 INFANTILE SPINAL AND CEREBRAL PARALYSES 

bone could be distinctly palpated anteriorly. The functional disturbance is 
very marked, for naturally the support of such a joint is impossible. 

Paralytic dislocations of the hip-joint are beautiful examples of the pre- 
viously described antagonistic-mechanical theory of Seeligmuller concerning 
the development of paralytic deformities. 

Paralytic luxations of the hip-joint are found only when definite muscle 
groups of this articulation are paralyzed, while their antagonists are still 
active. When the obturators and rotators of the thigh are incapable of func- 
tion, and the adductors, on the other hand, are normal, there is a paretic 
dislocation of the head of the femur upon the ilium which results in a para- 
lytic ilio-femoral luxation. The conditions are then about as follows : The 
tugging of the intact adductors, to which the paralyzed muscles can offer no 
resistance, causes first an adduction contracture, and later a dilatation of the 
posterior capsular wall. If to this is added the weight of the pelvis, the head 
of the thigh must be forced backward and upward against the ilium, and 
thereby cause a dislocation. 

Inversely, paralytic dislocation of the head of the femur will appear ante- 
riorly under the pubis — luxatio femoris paralytica infrapubica — when the 
power of the rotators and abductors is greater than that of the adductors. 

Eeclus and Karewski observed the development of paralytic dislocation 
from the preceding contracture while the patients were yet in bed. 

The symptoms of paralytic dislocation are conspicuous. There are usually 
other paralytic deformities in the same leg. Paralytic luxation upon the 
ilium presents the following picture: The dislocated leg is shorter than the 
other. The trochanter major of the dislocated member is high (6-7-9 cm.) 
above the Roser-Nelaton line. The region of the acetabulum is empty; upon 
rotatory movements the head of the femur is felt deep in the atrophic glutei. 
The affected half of the pelvis is atrophic. As a rule the adductors react 
"better to the electric current than the other muscles of the thigh. The leg 
may be adducted and fixed so that spontaneous abduction and outward rota- 
tion are impossible (Eeclus). 

In anterior paratytic dislocation the leg is flexed, abducted and rotated 
outward. Movability in the direction of extension and adduction is decreased. 
The dislocated head of the bone may be felt alongside the descending ramus 
of the pubis. The trochanter is hidden under the glutei. 

Reposition of paralytic luxation of long standing is impossible even under 
anesthesia. 

These contractures become more rigid in the course of time; the capsule 
of the joint and the ilio-femoral ligament contract more and more and com- 
pletely fix the joint in its pathologic position. As in contractures of the 
hip- joint after inflammation, here also there is a secondary development of 
lordosis of the lumbo-vertebral column. A compensatory lateral curvature 
of the spine also results from shortening of the paralyzed leg, due to static 
influences. 

In deformities of the knee-joint which follow infantile spinal paralysis, 



INFANTILE SPINAL PARALYSIS 549 

it must first be remarked that of the muscles of the lower extremity the 
quadriceps femoris alone is paretic, i. e., incompletely paralyzed — a condition 
by no means rare. Therefore contracture of the knee-joint does not occur, 
but, on the contrary, the joint becomes too motile, and always in the same 
manner: it is hyperextended and a genu recurvatum develops. The mech- 
anism of this deformity is comprehensible, v. Yolkmann has explained it 
convincingly by comparison with a pocket knife : " Take a pen-knife in the 
hand and support it upon a table by the point, the back of the knife being 
turned away. The blade corresponds with the lower leg, the joint with the 
knee, the clasp with the thigh, the hand, which holds the clasp, with the 
body of the patient. It is now possible, as will be at once apparent, by slight 
changes in the direction of pressure, to have the blade move in the joint. 
Everything depends upon how the power, which is represented by the pres- 
sure of the hand, maintains itself on the joint around which the blade moves. 
If the power falls posteriorly, i. e., upon the edge of the blade, the knife 
closes under too firm pressure; if it falls in front the knife opens, and when 
it is completely extended we may employ full power upon the handle." 

Exactly as with this pocket-knife is the mechanism of walking and stand- 
ing, the extensor muscles being paretic. The patient cannot actually extend 
his knee-joint. To place the lower leg forward he makes a pendulous move- 
ment of the extremity. If the knee-joint were flexed the patient would fall 
when the foot is placed on the floor because the resistance of the quadriceps 
is absent — just as the pocket-knife closes, in the manner described above, 
when the power is directed upon the blade. Therefore, to maintain equi- 
librium on his paralyzed leg the patient makes the body weight so act upon 
the knee as to bring this joint into a position of extreme extension and main- 
tain it thus. The leg can then bend neither anteriorly nor posteriorly. An- 
teriorly the weight of the body presses the joint surfaces of the femur and 
tibia firmly together. Posteriorly the ligamentous apparatus prevents the 
opening of the joint. Ligaments and bones must carry the entire body weight. 
Under this burden the ligamentous apparatus must necessarily suffer, par- 
ticularly as nutrition itself is not very good in consequence of general atrophy. 
Slow but constant relaxation occurs, so that the knee-joint is more and more 
hyperextended. 

The genu recurvatum paralyticum has developed. This does not inhibit 
walking; on the contrary, it makes it possible. 

Genu recurvatum still permits walking when there is paralysis of all of 
the muscles which move the knee-joint, and it is even possible for the patient 
to walk without crutches. 

The condition is different when the quadriceps is completely paralyzed but 
the flexor muscles remain capable of function. Then there is flexor contrac- 
tion of the knee-joint, exactly as is required by Seeligmiiller's theory. 

The mechanism of this contracture may be analyzed in one of my cases. 
After a complete paralysis of all four extremities the implication of the arms 
entirely disappeared; in the left lower extremity there was marked paresis; 



550 INFANTILE SPINAL AND CEREBRAL PARALYSES 

on the right side a complete paralysis of the quadriceps. In the lower leg 
only the pronators were exempt. 

Both knee-joints showed a flexion contracture. Flexion could be demon- 
strated actively and passively to the maximum extent. Extension, however, 
was incomplete on account of the contracture of the flexor muscle. Notwith- 
standing all treatment the boy collapsed more and more from increasing 
flexion of the hip- and knee-joints and therefore became smaller and more 
helpless in his movements. 

Finally, both legs were flexed at the knee-joint and both feet were in a 
high-graded position of valgus; the trunk, inclined strongly forward, rested 
upon the flexed legs, while the head was thrown somewhat backward. How- 
ever, this zigzag attitude was only possible when the patient supported him- 
self by both hands upon a cane, or placed his hands upon the anterior surface 
of his thighs. Walking was almost inhibited. When the patient attempted 
to raise the lower body he collapsed at once, like an inert mass. 

This collapse can be readily explained by his static posture. When the 
upper trunk was held vertically the weight served to increase the flexor angle 
of the knee-joints. 

On account of the incomplete action of the quadriceps the body necessarily 
had to collapse similarly as the pocket-knife. If, however, the trunk was 
inclined so far forward that the line of gravity was in the middle point of 
the angle of the knee-joint the weight of the upper body neither increased 
nor lessened this angle and equilibrium was established. If the inclination 
of the body forced the line of gravity in front of the middle point of the 
angle of the knee-joint the weight of the trunk forced an extension of the 
knee-joint and equilibrium was achieved by the action of the intact flexor 
muscles. The patient thus balanced his upper body between two antagonistic 
forces, the weight of the trunk, and the action of the intact muscles and the 
posterior surface of the thighs, and, notwithstanding paralysis of the quadri- 
ceps, he was able to stand and to walk with flexed knee-joints. 

If patients with complete paralysis of the quadriceps do not walk, but 
always slide around the floor, lie in bed, or move upon crutches, the flexor 
contraction of the knee-joints often becomes extensive. 

If all the muscles of the knee-joint are paralyzed a complete loose joint 
is not infrequent. 

There is another condition which I have often observed in paralytic legs 
wherein a marked atrophy of the quadriceps has developed. It is well known 
that in cases of this kind the knee wabbles and extensive lateral movements 
may be accomplished in the knee-joint. On the other hand I have found 
but little mention of the fact that these patients can frequently perform 
voluntary posterior subluxation of their tibia. I have found this in 4 cases 
in a most pronounced form. The great flaccidity of the capsule is probably 
responsible for this phenomenon. 

Three varieties of paralytic foot deformity must be differentiated. Per- 
haps one or several muscle groups are intact and pull the foot in their direc- 



INFANTILE SPINAL PARALYSIS 551 

tion, thereby producing a pes equinus, club-foot, flat-foot, talipes calcaueous 
or talipes cavus; or all muscles which control the ankle-joint may be paralytic 
and thus the loose foot develops. Therefore, in the first instance the foot is 
fixed, in the second case it is flaccid. Accordingly Schwartz and Riefel {Rev. 
d'Orthop., 1872) designate these forms of paralytic foot deformity as fixed 
and loose joints. 

A typical loose joint is rarely observed in the foot. If such a condition 
exists the weight of the foot causes an equino-varus. This analogous posi- 
tion is sometimes brought about by contraction of some of the bundles of 
the gastrocnemius which have escaped complete paralysis. If the equino- 
varus has persisted for some time there may be a secondary contraction 
of the gastrocnemius, the ends of which have permanently approximated 
one another. The joint is then fixed in the equinus position and we have 
fixation after a loose joint. Transitions from one variety to another are 
frequent. 

A few authors, notably, Boeckel, differentiate another paralytic foot 
deformity which is the result of tendon tugging or of destruction of the bone 
(pieds hots tendineux-osseux of the French). Naturally, the tugging of the 
non-paralyzed muscle, that is, of its tendons, is of primary importance; only 
secondarily — after a long or shorter existence of the deformity — does change 
in the bone take place. Attempts at redressment — under anesthesia — will 
readily determine with which of the two forms we are dealing. 

We must now consider the paralytic foot deformities individually. 

Paralytic club-foot is very common. It is especially frequent after paral- 
ysis of the motor nerves which supply the peronei and the extensores digi- 
torum longi et breves, therefore, when the entire muscle group is involved 
which supplies dorsal flexion and pronation to the foot. But club-foot may 
also develop after paralysis of the supinators and plantar flexors when the 
weight of the foot counteracts the power of the antagonists. When we enter 
into the symptomatology we will see that the paralytic club-foot is supinated 
so that the sole is turned inward and the dorsum outward, simultaneously 
with a distinct inward rotation and drooping of the tip of the foot. In addi- 
tion there is a conspicuous curvature of the toes; the great toe particularly 
is bent toward the sole of the foot and dislocated under the volar surface of 
the second toe. There is also atrophy of the lower leg and usually a short- 
ening of the entire extremity; clonus and a livid discoloration of the skin 
are noted. The history will establish the diagnosis. 

The development of paralytic pes equinus is easily explained. If the 
dorsal flexors of the foot are paralyzed the foot by its own weight assumes 
the position of pes equinus. This contracture may appear likewise after 
paralysis of all the muscles of the calf because the weight of the foot coun- 
teracts the action of the dorsal flexors. Occasionally we note the formation 
of a talipes cavus after a pes equinus. 

Paralytic flat-foot occurs usually in paralysis of the plantar flexors and 
supinators of the foot but it may also follow paralysis of all muscles. 



552 INFANTILE SPINAL AND CEREBRAL PARALYSES 

While paralytic pes equimis is usual in an immotile extremity and is 

caused by the weight of the anterior part of the foot, paralytic abduction — 
and pronation-contracture of the foot — paralytic flat-foot — commonly devel- 
ops when the limb is used in walking. The weight of the body overcomes 
the curvature of the foot and forces it into a flat position. The soft parts 
and bones adapt themselves to this false position but the change is very 
gradual, since it is opposed by the weight of the forefoot in every elevation 
of the limb from the floor and when the body is recumbent. 

There are also numerous cases wherein the pes valgus paralyticus arises 
without movement of the foot. These cases are an actual attestation of 
Seeligmiiller's antagonistic-mechanical theory. The plantar flexors and 
supinators of the foot are paralyzed. Each impulse of the will is only 
operative b} r means of the intact antagonists, the dorsal flexors and the 
abductors, and thus the foot assumes the position of abduction. Notwith- 
standing this very often the weight of the anterior foot predominates. Then 
while the entire posterior portion of the foot shows a high-graded abduction 
and pronation, the anterior portion assumes a flexion position so that the 
appearance of the member from beneath is very characteristic. In paralytics 
we not infrequently find one club-foot and one flat-foot. 

When the extensors of the foot and of the short plantar flexors are unini- 
plicated, and when there is complete paralysis of the long flexors, the active 
tug of the extensor may overcome the weight. of the anterior foot and cause 
a dorsal flexion, and thus the paralytic pes calcaneous sursum flexus develops. 
This dorsal flexion of the foot may occur even before the child begins to 
walk. The deformity is usually aggravated by walking, and may attain a 
very marked grade. I have had such a patient under treatment. W r hen 
walking, particularly if a genu recurvatum has arisen from insufficiency of 
the quadriceps, a part of the heel rests upon the floor which does not belong 
to the walking surface but is somewhat above the sole, toward the insertion 
of the Achilles tendon. In so far as the extended ligaments and the greatly 
deformed bones permit such locomotion, at the moment when the paralyzed 
foot comes into support and the body swings forward upon it, the calcaneus, 
which can no longer be controlled by the paralyzed muscles of the calf, is 
displaced anteriorly. 

The paralytic pes calcaneus is frequently associated with a valgus posi- 
tion of the foot. As the patients grow older the weight of the anterior foot 
gradually bends the tarsus toward the planta and we then have the paralytic 
talipes cavus. 

After this brief description of infantile spinal paralysis it need only be 
added that we not infrequently meet with cases in which paralysis of both 
lower extremities is combined with paralysis of the muscles of the back. As 
in all paralyses which occur in anterior poliomyelitis, we are here dealing 
with flaccid paralysis, i. e., paralysis without spastic s}miptoms. Spastic 
symptoms, on the contrary, characterize the infantile cerebral paralyses. 



INFANTILE CEREBRAL PARALYSIS 553 



INFANTILE CEREBRAL PARALYSIS 

Passing to infantile cerebral paralysis, this in its various forms presents 
a large and in certain cases an extraordinarily profitable field for surgical 
orthopedic therapy. These patients invariably suffer from spastic contrac- 
tures. These contractures are characterized by the shortened muscles, which 
are elastic but at once retract when the tension is relaxed. This gives a 
sensation of " springiness " upon attempted movement. Freud has attempted 
in his recent excellent monograph to classify the various forms of the dis- 
ease which in general belong to the group of infantile cerebral paralyses. 
His division seems justifiable from a pathologico-anatomical aspect; in a 
clinico-practical sense, however, it is not so good. From a purely practical 
standpoint I should like to propose the classification of the cases into four 
great groups. It is true there are transitions from one group to another, 
but all of the unquestioned cases which come to us for treatment may be 
placed in one of these great groups. This is essential, for the individual 
prognosis, at least in my experience, depends upon our classification of the 
case after a careful examination. 

The first group comprises those cases which present spastic muscular con- 
tractures, especially when confined to the lower extremities. The upper 
extremities are exempt, the intelligence well retained, but usually there is 
strabismus. These are the only cases which should be designated true Little's 
disease. I know that the excellent description of Little also includes cases 
of other groups, but we must go further and separate these cases clinically. 
However, when the spastic affection only extends to the lower extremities, 
leaving the upper limbs entirely free and the intelligence intact, and when, 
as is the rule, there is some strabismus, these cases are clinically so charac- 
teristic that they may be easily distinguished from the other forms. There- 
fore, in the further description of such cases I shall refer to typical Little's 
disease, or to typical cases of so-called congenital spastic rigidity (Rupprecht). 

The second great group embraces those affections in which not only the 
lower out also the upper extremities are attacked. Here, therefore, rigidity 
is general. This group is designated by me as cases of general spasticity. 
These are contractures in the legs and in the arms. Simultaneously, as a 
rule, we have cerebral derangements (strabismus, disturbance of speech, 
clouded intelligence and, not infrequently, epileptic attacks). 

The third great group includes athetosis. 

The fourth group is comprised of cerebral hemiplegias. These cases are 
also well characterized. We will now devote our attention to the individual 
groups. 

Group I: Little's Disease; Congenital Spastic Rigidity. — The first accu- 
rate reports of congenital spastic rigidity were by Delpech, who demonstrated 
that abnormal innervation of the muscles may permanently destroy the nor- 
mal position of bones. Eeports were also published by Heine. ■ The first 



554 



INFANTILE SPINAL AM) CEREBRAL PARALYSES 



accurate knowledge of the disease, however, originated in England, about the 
middle of the preceding century, when Little described the affection as a 
disease sui generis. His name has therefore been given to the malady. 
Recently there have been many contributions to the subject. 

Particular mention must be made of the labors of Erb, Striimpell, Rup- 
precht, Naef, and Feer. The most complete dissertation, however, is that of 

Freud, who investigated the 
nature of the disease, while 
Lorenz and Schulthess con- 
cerned themselves with treat- 
ment. 

Little's disease is not un- 
common; it occurs in the pro- 
portion of 4 to every 100 cases 
of deformity. Naef calculates 
that among every one hundred 
hospital children there is one 
with this disease. Thus far I 
have seen 21 cases. The affec- 
tion is equally common among 
boys and girls. It is not al- 
ways recognized at birth, at- 
tention being first drawn to it 
perhaps when the child begins 
to walk, and it is usually at 
this period that the case is 
brought to the physician for 
treatment. 

The lower extremities are 
always implicated, usually to 
an equal extent. 

In children the legs are 
commonly rotated inward and 
strongly adducted (Eigs. 13 
and 14), so that they are often 
crossed. In adults this is less 
marked, and the inward rota- 
tion may be entirely lacking 
because the adductors usually 
are not implicated to the 
same degree as in children. 
The hip- and knee- joints are 
slightly flexed. The position 
of the feet may be diverse : a bilateral true pes equinus is rare. As a rule there 
is a bilateral pes equino-varus, but it is relatively common to find upon one 




Fig. 13. — Little's Disease in Child, Showing the 
Inward Rotation and Adduction of the Legs. 



INFANTILE CEREBRAL PARALYSIS 



555 



side a pes equino-varus and upon the other a pes equino-valgus. The feet of 
very young children usually show a quite normal position during repose ; the 
abnormalities appear only upon first attempts to walk and are due to the tension 

of the muscles of the calf. Ac- 

cording to Schulthess a length- 
ening of the quadriceps tendon, 
the lig amentum patella? prop- 
Hum, which leads to a high 
position of the patella and 
produces a peculiar sharp ap- 
pearance of right-angled flex- 
ion of the knee-joint, is a 
pathognomonic sign of spastic 
spastic rigidity. Schulthess 
designates this elongation as 
a functional change of the 
tendon. 

The trunk is inclined for- 
ward and is rigid. All move- 
ments are awkward. The step 
is short and hasty. The raised 
foot slides over the floor on its 
tip and when planted firmly it 
is placed either in front of or 
over the other foot. The 
knees strike each other during 
walking. In well-developed 
cases there is a very percepti- 
ble lateral movement of the 
trunk and shaking of the head. 
Usually a cane is required, or 
the patients cannot walk with- 
out an attendant. Stejjping 
is particularly difficult. The 
child is either backward in 
sitting up or does not do so 
at all because of its inability 
to properly flex the thigh 
upon the pelvis. 

The upper extremities, as already mentioned, are usually exempt, but this 
rule is not absolute. If they are affected, the upper arm is usually held 
firmly against the trunk, the elbow- joint is flexed, and the hands are pro- 
nated and flexed toward the palm and ulna. The fingers are extended or 
even hyperextended. 

The sternocleidomastoid, the muscles of the nape of the neck, and the 




Fig. 14. — Same Case as Fig. 13, Posterior View 



556 INFANTILE SPINAL AND CEREBRAL PARALYSES 

muscles of the face may also be involved in the disease. In some cases the 
muscles of the eye are not exempt and we find strabismus which differs in 
no way from the ordinary form, and is usually convergent, as is the general 
rule. The eyes are free and move unhindered; the movements are not rigid 
nor spasmodic. Osier found nystagmus in 4 cases, and in 2 instances he 
noted atrophic papillae. 

The muscles of speech are often more or less involved. The child is 
backward in learning to speak. According to Feer in about 14 per cent, of 
the cases there is a slightly hindered, jerky, slow or dragging articulation. 

The course of the disease is chronic, regressive or stationary. The power 
of the muscles, the electric contractility, and sensation are completely retained. 
Only the muscle tonus is abnormally increased. The quiescent muscle does 
not feel tense, but as soon as active or passive movements are attempted it 
at once shows a condition of tonic rigidity and presents an uneven surface. 
This is most marked in the muscles of the calf, the adductors of the thigh, 
and in the flexors of the lower leg. The antagonists of these muscles are 
also usually hindered in their movements. The affected muscles are com- 
monly well developed. Their power is not decidedly diminished; voluntary 
movements may very readily be made if the attention of the patient is 
diverted. According to Adams the structure of the muscle shows little 
change. With insufficient exercise or entire disuse of the muscle atrophy 
will gradually appear, but it only becomes decided when for years the extrem- 
ity has not been moved or exercised. In time actual shortenings of the most 
tense muscles may occur which give rise to permanent contracture; the most 
obvious changes are flexion and adduction of the hip- joint, strong flexion 
of the knee-joint, and the development of a pes equinus, club-foot or 
equino-varus. 

Besides rigidity of the muscles there is increased tendon reflex which is 
a most noteworthy s}miptom of spastic rigidity. The intelligence is more or 
less intact; in mild cases it shows no disturbance, in others, however, there 
are all possible degrees of dulness up to complete idiocy. One of my patients 
frequently had maniacal attacks. Among our cases we find those with a high 
grade of intelligence, and again those in whom this function has suffered; 
we must be very careful not to be misled by the facial expression or by some 
error in speech which is so common in this disease, and to conclude there- 
from a deficiency of intelligence which in fact does not exist. Convulsions 
appear early, usually in the first months, and almost always during the first 
year; they recur periodically, then grow less frequent, and may finally dis- 
appear, but sometimes they continue throughout life. 

Etiology. — Little has arrived at the conclusion, based upon the observa- 
tion of a large number of cases, that the cause of this disease is to be referred 
in almost every instance to a premature, difficult, or asphyxiated birth — a 
view which has been confirmed by later investigators. Feer found that the 
cases without cerebral symptoms may be the result of premature delivery. 
On the other hand, the cases with brain symptoms are to be referred to hard 



INFANTILE CEREBRAL PARALYSIS 557 

or asplivxiated labor. In my patients also the history of a premature or 
difficult labor was found. Xarrow pelvis of the mother, prolapse of the cord, 
primipara, etc., are sometimes causal factors. 

The appearance of the disease in several children of the same family is 
frequently mentioned. Most noteworthy in this respect are the three chil- 
dren in one family, treated by Schultze. One of my patients had a brother 
suffering from the same disease. All of the other children were quite nor- 
mal ; their birth was spontaneous, while that of both the patients was arti- 
ficial. There is no case on record in which heredity has been established. 

Pathologic Anatomy. — Difficult labor, mentioned above, gives rise to 
traumatic meningeal hemorrhages which are the principal etiologic factors 
in Little's disease. According to A irehow these hemorrhages result from 
tearing of the veins in the subarachnoid tissue where they empty from the 
pia into the large cerebral sinus, and are caused by the forcing together of 
the parietal bones. A further etiologic factor is intracerebral hemorrhage 
from rupture, thrombosis, or embolism. In how far inflammatory processes 
are concerned is yet to be determined. In any event inhibited development 
of the brain and disturbances of the pyramidal columns must be considered. 

How such disturbances produce spastic muscular contracture may be dem- 
onstrated as follows : The motor conduction from the brain to the muscle is 
brought about by two neurons. One neuron proceeds from the cortex of the 
brain through the pyramidal tract to the ganglion cells in the gray anterior 
horns, and the other from here to the muscle. 

Motion of the muscle is possible through the peripheral neuron alone; 
in fact every reflex takes place, in that the stimulation of the sensory fiber 
of the peripheral neuron passes to the anterior horn and from here through 
the motor fiber to the muscle. The reflex is an involuntary movement of the 
muscle. The will comes into play only as a regulating factor through the 
action of the central neuron upon the periphery, i. e., it inhibits the reflex 
movement. 

Therefore, whenever the cortical motor neuron is damaged the reflex 
movements must be increased. In our case we cannot be dealing with a com- 
plete interruption of the tract which extends from the cerebral cortex to the 
anterior horns. TTere this the case every voluntary movement of the stiffened 
muscles would have to be arrested. But we have already found that the rigid 
muscles possess the faculty of voluntary movement, therefore have not lost 
it entirely: that, on the contrary, the patients are able to produce movement 
in their joints, although at first great energy may be required. From this 
it must be assumed that the disturbance which we find in our patients can- 
not be referred to an interruption in the course of the cortical motor neuron 
but only to its decreased action, therefore to a disturbance in function. This 
fact is exceedingly important ; it shows how we are to conduct our treatment. 
With all the remedies at our command ice must attempt to raise the energy 
of the cortical motor neuron and to decrease the effect of the peripheral neuron. 

Progxosis. — Complete recovery is very doubtful. Spontaneous improve- 



558 INFANTILE SPINAL AND CEREBRAL PARALYSES 

nu'iit has been observed. Actual aggravation is rare; in the worst forms the 
affection remains stationary. Those cases are most favorable, although few, 
in which there is but slight implication of the muscles which pass from the 
pelvis to the upper and lower leg. If contractures, marked shortening of 
the muscles, and atrophy have already appeared a favorable result can be 
attained only by determined effort. 

Group II: Cases of General Spasticity. — This group is characterized by 
spastic contracture of the arms as well as of the legs. In addition there 
are, as a rule, deficient intelligence, disturbances of speech and of sight, and 
occasionally epileptic attacks. These unfortunate patients we cannot aid much 
by any form of treatment. In one case upon which I operated death ensued, 
and I must therefore caution against operative interference in such patients. 

Group III: Athetosis. 1 — The symptom-picture which we designate athe- 
tosis comprises the third group. The etiology of this disease is obscure, but 
the insignificant contractures, the paretic symptoms and the spontaneous 
movements are its distinguishing features. Little can be said of the pathol- 
ogic anatomy. Strumpell thinks it likely that there is always a cerebral 
(perhaps cortical) disturbance, but the autopsy findings have not yet fully 
substantiated this view. The disease commonly attacks the upper extremities 
and preferably the terminal members, which show almost constant, involun- 
tary, irregular movements of varying intensity. The legs are usually less 
implicated. The gait is, as a rule, spastic-ataxic in consequence of the com- 
mon combination of athetosis with spastic paraplegia. There are tic-like 
spasms of the facial muscles which may increase to restless activity. Dis- 
turbances of intelligence and speech are more or less marked. The general 
clinical picture is so distinct that after one such case has been observed 
diagnostic error is scarcely possible. 

Group IV : Cerebral Hemiplegia. — In the fourth group of infantile spastic 
contractures I have classed cerebral hemiplegia. 

Although in this disease there is a similar pathologico-anatomical change as 
in congenital spasticity, nevertheless the clinical picture is so characteristic 
that cerebral hemiplegia may be quite properly differentiated as a special form. 

All authors agree that the affection commonly arises in the first three 
years of life and is rare after this period. Although congenital hemiplegic 
cerebral paralyses are not unknown, nevertheless the overwhelming majority 
of patients acquire the affection extrauterine. According to Arend almost 
one-third of the cases may be referred to some infectious disease (measles, 
scarlet fever, particularly syphilis). In one-half of the patients an etiologic 
factor cannot be found, and the remaining cases are referred to fright and 
to trauma of the head. According to a large number of writers (Heine, 
Richardiere, Sachs) heredity also plays a role. 

The child, who previously has been well, is attacked suddenly with severe 
or with less marked initial symptoms (vomiting, fever, convulsions) which 

i See volume on " Diseases of the Nervous System," p. 899. 



DIFFERENTIAL DIAGNOSIS 



559 



are succeeded by a hemiplegic paralysis which, as the name suggests, affects 

one side of the body. Combined with this there are often aphasia and 

disturbances of speech and intelligence. The 

frequent appearance of post-hemiplegic chorea 

and epilepsy renders the prognosis grave. The 

paralysis is referred particularly to the arm and 

leg; less often the face is implicated. 

The upper extremity is commonly attacked 
more severely than the lower, and improves less 
rapidly. The reflexes are usually increased. On 
the other hand, sensory disturbances are rare. 
At first the paralysis is flaccid; only gradually 
does contracture appear, which, however, is never 
very marked. 

The position of the paralyzed extremities is 
particularly characteristic. The arm is pressed 
against the trunk, the forearm is in half prona- 
tion and is flexed at a right angle with the 
upper arm. The elbow rests against the body. 
The hand is flexed toward the ulna, the fingers 
bent more or less decidedly toward the palm, 
covering the thumb (Fig. 15) . The leg is rotated 
slightly inward and sometimes shows moderate 
flexion of the lower toward the upper leg with 
extension of the foot. The tip of the foot is 
turned inward, and suggests an equine-- varus. 
In the majority of patients the great toe is raised 
at a right angle to the metatarsus. 

The diagnosis of hemiplegia may usually be 
made at once. If the child is seated upon a level 
the arm assumes the characteristic position above 
described, and the knee of the same side will not rest upon the surface. 




Fig. 15. — Cerebral Hemiplegia. 



DIFFERENTIAL DIAGNOSIS 

A few words must now be devoted to the differential diagnosis of infan- 
tile spinal and cerebral paralysis. This is best done by a contrast of the 
principal symptoms. 



Infantile Spinal Paralysis. 

As a rule suddenly, after a febrile 
disease, in an otherwise normal child. 

Usually without spasmodic symptoms. 



Origin 



Onset 



Infantile Cerebral Paralysis. 

Often premature birth, or severe labor, 
with marked asphyxia. 

Frequently with convulsions. 



560 INFANTILE SPINAL AND CEREBRAL PARALYSES 

Nature and Distribution of the Paralysis 
All of the extremities are commonly The paralysis affects both lower ex- 

attacked; later the paralysis subsides tremities, or is frequently unilateral; 

in most of the muscles and is there- very often there is a simultaneous 

after limited to one extremity or facial paralysis. The paralysis is 

muscle group. spastic. 

The paralysis is flaccid. 

Reflexes 
Usually absent. Always increased. 

Electric Reaction 
Frequent De R. Faradic and galvanic normal. 

Mental Development 
Normal. Often deficient. 

Eyes 
Normal. Very frequently strabismus. 

A discussion of infantile spinal paralysis as contrasted with other similar 
diseases would lead us too far; I shall only remark that the differentiation 
of spinal paralysis from progressive muscular atrophy, acute transverse mye- 
litis, cerebrospinal meningitis, diphtheritic and pseudohypertrophic paralysis 
is to be considered. 

PROGNOSIS 

The prognosis of both paralyses has already been indicated. A detailed 
discussion is unnecessary; as has already been stated, the prognosis of both 
affections, thanks to the advance of orthopedic surgery, has improved in the 
last decades to an extraordinary extent. Even in the severest cases of infan- 
tile spinal and cerebral paralysis we are to-day able to attain surprising results 
and to give returned freedom of movement to children who in earlier times 
would have been permanently crippled. 

TREATMENT 

It is impossible for me to detail the treatment of the individual forms 
of paralysis. For this I must refer the reader to text-books on orthopedic 
surgery. On the other hand, it is quite easy to sketch the general funda- 
mental principles under which the treatment is to be conducted. 

We will first consider the general treatment of paralytic contractures, 
which is to be instituted as early as possible. Paralysis resulting from ante- 
rior poliomyelitis shows in its first stage, as we have seen, a great tendency 
to spontaneous cure. This is evinced by the fact that, as a rule, the paralysis 
of the limbs originally affected rapidly decreases and limits itself to a defi- 
nite group of muscles. But the paralysis, with its sequelae, should not be 
permitted to become permanent. From the beginning w^e should assist it 
in its attempts at self-cure. Therefore, the child attacked by poliomyelitis 
should be treated from the onset of the paralysis by methods directed against 
rigidity of the muscle and to prevent paralytic contractures. 

The administration of internal medicaments such as strychnin or ergotin, 



TREATMENT 561 

so recently in common use among physicians, is not advisable. These rem- 
edies may be prescribed, but local treatment of the paralysis must be insti- 
tuted from the beginning. This is and will remain the principal factor in 
the therapy of these diseases. Therefore, at the onset of the malady there are 
two indications to fulfill : First, to combat the paralysis, second, to prevent the 
development of paralytic contractures. 

The greatest success in bringing about function of the paralyzed muscle 
is offered by the long-continued electric treatment of the muscles by gal- 
vanization. A large, broad electrode, used as the anode, is placed upon the 
vertebral column at a point corresponding to the lesion in the spinal cord — 
therefore, in paralysis of the upper extremities, upon the cervical vertebrae; 
in paralysis of the leg, upon the thoracic vertebrae ; in paralysis of the bladder 
and rectum, upon the lumbar vertebrae — while the other electrode, used as a 
cathode, is placed peripherally over the paralyzed nerves and muscles, or the 
individual muscles are stimulated by a stabile current or by Voltaic alterna- 
tives. Quite powerful currents must be used. These are applied for two or 
three minutes and are concluded by a few changes in the current to produce 
contraction of the muscle. This method of electrical application is painful 
and can be accomplished only under energetic treatment. The parents of 
the child should not be allowed to make the applications. If no contraction 
of the muscle is produced we alternate the constant with the faradic cur- 
rent, one day using the constant and upon the succeeding day the faradic. 
Occasionally tenotomy of the contracted muscles is necessary. This relieves 
the tugging of the shortened muscle and lengthens the tendons by allowing 
the paretic antagonists more space and freer movement. The antagonists 
then offer little or no resistance, so that the muscles contract more readily 
under the current (Billroth). 

The electrical applications should be followed by massage, gymnastics, and 
redressment manipulations. Effleurage, petrissage, and tapotement are prac- 
tised upon the muscles, and the joints are pushed into their normal positions. 
The use of these muscles, no matter how little, is advantageous. The active 
movements are then utilized as much as possible, and gradually opposition 
is exerted which includes movements of slight resistance. For parah-tic con- 
tractures of the upper extremity the use of Krukenberg's automatic pendular 
apparatus is advised. 

The parents are instructed to give the children, before they are brought 
to the physician, warm baths at a temperature of 26° to 28° C. (78.8° to 
82.4° F.) which last ten to fifteen minutes, and after the bath to use spirits 
of camphor or of mustard, formic ether or alcohol. The vital energy of 
the paralyzed parts is decidedly stimulated by this treatment. 

After electrization and mechanotherapy, the patient should be placed at 
once in a suitable apparatus to prevent contraction of the paralyzed muscles. 1 
I strongly advise the Hessing's apparatus (Schienenhulsenapparat), for we 

i The same advice is given by Gibney. — Editor. 



562 ENFANTILE SPINAL AND CEREBRAL PARALYSES 

have learned to appreciate the excellent effect of this above all other mechan- 
ical appliances. With the aid of such apparatus, in combination with a 
supporting corset (combination paralysis apparatus), standing and walking 
may be accomplished even with complete paralysis of the lower extremities. 
The apparatus is worn constantly, but it may be removed before the morn- 
ing bath and also before retiring at night, at which time the paralyzed limb 
should be wrapped in warm cloths for about an hour and then massaged. 
I have found dry heat to be of considerable value in the regeneration of 
muscular and cutaneous functions and particularly advise its application. 

These simple measures, which must be employed rationally, often bring 
about a very satisfactory result, even in cases apparently desperate. At least, 
if we do not entirely conquer the paralysis, the children are again placed 
upon their feet and locomotion is possible, whereas otherwise they would 
have been condemned to remain cripples for life. 

Even if the child does not come under treatment until after contractures 
have developed, we must still attempt to reproduce normal function of the 
joint by the use of electricity, mechanotherapy, baths, inunctions, and the 
application of dry heat. In addition, an important factor is the actual ortho- 
pedic surgical treatment, which endeavors to effect a complete rehabilitation 
of the normal form and shape of the limbs. 

Kedressment of paralytic contractures in general is much easier than of 
congenital deformities and should first be attempted by the hands alone. If 
this method is unsuccessful tenotomy should be performed or division of 
all of the soft parts which prevent the straightening of the part of the body 
involved. Operation upon the bone is rarely necessary. After completed 
redressment an apparatus is applied which permits movement of the joints. 
The extinct muscular action is replaced by artificial muscles in the form of 
elastic bands. Therefore, in proportion to the severity of the disease very 
good results are attained, and we might say that by the rational and methodic 
employment of all the methods at our command, the greater the paralysis 
and deformity the more remedial agents we possess. 

Notwithstanding the treatment just described there yet remain a number 
of cases in which we fail to accomplish the desired result. These are the 
cases in which poliomyelitis has led to flail-joint or to complete paralysis of 
all muscles of the extremity so that they cannot function. It is true, even 
here locomotion is possible with the aid of suitable braces, but the patients 
are naturally caused much inconvenience throughout life by being confined 
to such apparatus. By artificial stiffening of the joints the legs may to a 
certain extent act as stilts; the operation employed for this purpose — arti- 
ficial anchylosis of paralyzed joints — is designated arthrodesis, as proposed 
by its originator, Albert. 

Arthrodesis may be indicated in the upper as well as in the lower extrem- 
ity. The desired osseous anchylosis can only be brought about by a surgical 
opening of the joints, freshening of the joint ends, and their direct union; 
often, however, we must content ourselves with a fibrous adhesion. Arthrod- 



TREATMENT 563 

esis is only to be resorted to when the rational employment of all other 
methods of treatment has failed. 

Attempts have been made to bring about an artificial increase in the 
growth of bone (first reported by Oilier), and thus attain either an osseous 
arthrodesis or a lengthening of the shortened member. Under this category 
must be mentioned cauterization of the diaphysis of the bone, periosteal 
scarification, puncture with nails, passive hyperemia, and painting with iodin. 
The last two methods have shown particularly good results after arthrodesis. 

Transplantation of tendons, a method which has lately been much dis- 
cussed, must be somewhat explicitly described at this point. In an otherwise 
incurable muscular paralysis the tendons of normal but less important neigh- 
boring muscles are transplanted to tendons which have lost their power to 
function, and the activity of the normal muscles is thereby transmitted to 
those which are affected. Tendon transplantation is an invention of Xicola- 
doni, who first employed it in the cure of a pes calcaneus with paralysis of 
the muscles of the calf. The peroneal muscles were cut behind the malleolus, 
then the Achilles tendon was severed above the heel and its stamp sewed to 
the central ends of the peroneal tendons. Adhesion took place and the result 
was excellent. 

In the last few years Mcoladoni's operation has been frequently employed 
and advised. To-day not only the original operation of Xicoladoni — the trans- 
mission of function of a normal muscle to one that is paralyzed — is in use, 
but also a division of the function of a muscle so that its tendon is only 
partially sewed to the paralyzed muscle. 

To bring a normal muscle into contact with one that is paralyzed three 
methods must be considered: 

1. The tendon of a perfectly functionating muscle can be severed and 
attached to the tendon of the paralyzed muscle in its central stump, thereby 
giving new power to the affected muscle; this method is not often employed 
and then only when the normal muscle can be spared from its allotted work, 
for otherwise a complete extirpation is impossible without damaging the 
activity of the affected limb. As an example I may mention the trans- 
plantation of the normal flexor carpi ulnaris to the paralyzed extensor digi- 
torum communis. 

2. The second feasible method in tendon transplantation is severance of 
the tendon of the paralyzed muscle, its central stump being left entirely out 
of consideration, the peripheral end, however, being sewed to the normal 
muscle as much centrally as possible. For example, let us consider a para- 
lytic pes equinus with involvement of the tibialis anticus but with retained 
power of the extensor digitorum communis longus. The tendon of the tibialis 
anticus is separated, the foot is brought into the greatest possible dorsal 
flexion, and the peripheral end of the tibialis anticus is sewed as far cen- 
trally as possible to the tendon of the extensor digitorum communis longus. 
Thus the ankle remains in dorsal flexion by the existing tension, but after 
adhesion of the tendon the over-contraction of the extensor digitorum com- 



564 INFANTILE SPINAL AND CEREBRAL PARALYSES 

munis raises the peripheral part of the tibialis and thus brings about a 
condition resembling contraction of the tibialis. 

3. The third modification of tendon transplantation is as follows: About 
one-half of the tendon of a completely normal muscle is separated and sewed, 
in the necessarily corrected position of the joint, to the tendon of the para- 
lyzed muscle. Most frequently a portion of the Achilles tendon is employed 
so as to utilize the power of the muscles of the calf for the activity of the 
paralyzed peroneal muscles, the paralyzed tibialis anticus, or the paralyzed 
extensors of the toes. 

Vulpius has proposed that the operation in which the whole or part of 
the tendon of a paralyzed muscle is sewed to the tendon of a functionating 
muscle be called an ascending transplantation ; the operation in which the 
functionating tendon or a portion of it is sewed to a paralyzed tendon a 
descending transplantation. I suggest the term passive transplantation for 
the first form, because here an inactive, passive tendon is sewed to a normal 
one ; for the second form the term active transplantation because here the 
tendon of an active muscle is transmitted to a paralyzed muscle. The com- 
bination of the two methods, which Vulpius designates bilateral transplanta- 
tion, we would call active- passive transplantation. 

A special form of tendon transplantation is the method advised by Lange 
— periosteal tendon transplantation. In this the muscle which conveys the 
power is not sewed directly to the paralyzed muscle but to the periosteum. 
Thus new muscular insertions are produced on the bone which do not exist 
normally and the desired function is established in a favorable manner. 

For example, in paralysis of the extensor digitorum pedis a split portion 
of the tibialis anticus would be sewed to the dorsal side of the cuboid bone. 

This method has decided advantages, particularly in that no atrophic 
tendon is emplo}^ed in the formation of the new muscle. 

Hand-in-hand with these active, passive, or active-passive tendon trans- 
plantations other operations which are designated tendon shortening or ten- 
don lengthening are practised with serviceable results. According to my 
experience a combination of these with the foregoing methods is most 
profitable. 

Tendon shortening may be effected in two ways : Either the tendon is 
severed with its ends approximating, and after the greatest possible stretch- 
ing the severed ends are sewed together; or shortening is caused by the for- 
mation of folds, the tendon being run through with a strong silk thread, the 
ends of which are firmly fastened. 

Tendon lengthening is accomplished, according to Bayer, by a stepwise 
splitting of the tendon, stretching of both ends, and the sewrng of the trans- 
verse section. 

This is not the place to discuss the technic of actual tendon transplanta- 
tion. It is evident that before proceeding to this we must determine upon 
an exact plan of operation, and for this an accurate electrical examination 
of the muscles is absolutely necessary. If this procedure does not enable us 



TREATMENT 565 

to decide whether the affected muscle is entirely or only partially paralyzed, 
we may determine that condition during the operation from the color of the 
muscle. The strongly functionating muscle is dark red; the paralyzed one, 
in consequence of fatty degeneration, yellowish white; the paretic muscle a 
varying rose red. 

After tendon transplantation the affected memher is fixed in a plaster 
bandage in a hyper-corrected position. After three or four days the skin 
sutures are removed through an opening in the cast. In four to eight weeks 
the cast is removed and the after-treatment by massage, gymnastics and 
electricity is instituted and continued for some weeks. 

The result of transplantation can be noted often after a few weeks. In 
other cases the desired effect arises gradually. Again, we must be satisfied 
if only the abnormal position of the joint is overcome and a permanent cor- 
rection of the deformity has been attained. 

In what manner the functionating muscle is stimulated to renewed activ- 
ity is a very interesting physiologic question, but has not yet been definitely 
decided. To a certain extent a new muscle is produced by the transplanta- 
tion which, through adaptation of the cerebral cortex, gradually reaches a 
certain substantiveness of innervation and function. It is a curious fact 
that not only such muscles may be utilized for the transmission of power 
as are functionally closely related to the paralyzed ones, but also other mus- 
cles of quite opposed action may be employed without a poor result. 

We will now turn to the treatment of spastic contracture, which we have 
learned to recognize as a symptom of cerebral diplegia. 

We begin with the treatment of Little's disease, which was formerly known 
as congenital spastic rigidity. 

The treatment of these cases can only be symptomatic ; as already men- 
tioned, the voluntary stimulation of the muscles is not altogether lost but only 
decreased, and we must therefore attempt to strengthen this by exercises and 
practice. With perseverance and rational treatment good results may be at- 
tained, and the patients will often make great progress as soon as they have 
overcome the first difficulties. A complete cure is naturally impossible, but we 
may so improve the condition that the patient can move about without foreign 
aid — a result which has attended all of my cases. 

As we have seen, the flexors and adductors predominate over the extensors 
and abductors. It must therefore be our aim to reinforce the disturbed 
equilibrium between these opposing muscles. We must attempt to strengthen 
the extensors and abductors and weaken the flexors and adductors. The 
former is accomplished by massage and gymnastics. The muscles are kneaded 
twice daily. Systematic exercises are then instituted and continued for a long 
time. I begin with passive movements of the individual joints, first of the 
ankle, then the patient attempts active movement. After this treatment has 
been maintained a sufficiently long time and is easily performed by the pa- 
tient, resistance movements are employed. I have my older patients practise 
daily with the Krukenberg pendular apparatus. 



566 



INFANTILE SPINAL AND CEREBRAL PARALYSES 



To weaken the flexors and adductors a special form of massage is employed, 
namely, energetic tapotement of the affected tendon ends. We have found 
empirically that this tapotement acts promptly in relieving spasm. 

However, if the muscles are very rigid and marked contracture exists, 
tapotement is not sufficient; then, to weaken the muscles, tenotomy or ten- 
onectomy must he performed. 

By tenotomy or tenonectomy we lengthen the affected muscles and thus 
secure the desired release of the contracture. The adductors, the muscles of 
the popliteal space, and the Achilles tendon here come into consideration and 
it is advisable to cany out all of these operations with the patient in the 
sitting posture and subsequently to encase the joints in a plaster cast in a 
hyper-corrected position. Special care must be had that the legs are rotated 
sufficiently outward in the cast. This plaster cast is worn four to six weeks, 
at which time the contractures should have disappeared. But this by no means 
terminates the treatment; on the contrary, the principal object yet follows, 
i. e., the patients are taught to stand and walk by suitable gymnastics and 
massage. If this is overlooked we naturally will fail to have a good result. 
Strohmayer, who has seen only negative results from tenotomy, is certainly in 
error when he maintains that the operation is useless ; it is only useless when 

no suitable after-treatment is 
employed. 

T endino plasty is also of 
great value in the treatment 
of spastic contractures in so 
far as the method of Eulen- 
burg and Sonnenburg has 
demonstrated that a portion of 
the surplus power of the spas- 
tic-ally contracted muscle may 
thereby be transmitted to its 
antagonist and thus weaken 
the spastic muscle. At the 
same time it strengthens the 
antagonist; for example, in 
spastic clubfoot a portion of 
the Achilles tendon is trans- 
ferred to the peronei or to the 
extensors of the foot. I have 
repeatedly operated by first 
separating a portion of the 
Achilles tendon for transplantation upon the extensors and then lengthened 
the remaining part of the tendon by Bayer's method. Thus one operation 
enables us to elongate the Achilles tendon, to relieve the plantar flexion of 
the foot, and to transplant a portion of the Achilles tendon for the trans- 
mission of power to the muscles that are to be strengthened. 




Fig. 16. — Splint for Infantile Paralysis. 



TREATMENT 



567 



^ 




The after-treatment has for its purpose to maintain the hyper-correction 
of the joints. Lorenz places bags of shot upon the joints. I have employed 
instead a simple apparatus 
in which the patients are 
placed twice daily for two 
hours after massage (Fig. 
16) . It consists of two boards 
which are united by a joint 
which allows them to spread. 
The degree of the angle may 
be read from a scale on a 
steel plate which is placed 
at the bottom of the board. 
At the middle there is a 
leather strap which encircles 
the knee and holds it in posi- 
tion. At the lower end there 
is a movable foot-brace to 
which the feet are strapped. 
With this apparatus I am 
able to abduct the leg, to 
extend the knee-joint, and to 
rotate the limbs externally as 
far as is desired. 

After the patients have 
remained in this brace a suf- 
ficient time, walking exercises 
in a combined paralysis ap- 
paratus are permitted (Fig. 
17), first with the aid of 
Heusner's walking frame, 
then upon two sticks, and 
finally without any assist- 
ance. In these walking ex- 
ercises it must be particu- 
larly observed that the 
patients plant the feet firmly 
and do not stamp, but as- 
sume as elastic a step as 
possible. 

After the walking ex- 
ercises gymnastics should be 

practised which have for their purpose the subjection of the muscles to the 
will of the patient. Flexion and extension of the ankle-joint, abduction and 
adduction of the foot, flexion and extension of the knee-joint, abduction and 




Fig. 17. — Combined Paralysis Apparatus. 



568 



[NFANTILE SPLMAL AM) CEREBRAL PARALYSES 



outward rotation of the hip-joint, are the movements J employ in my cases, 
actively and passively, with and without aid. The ataxia of these patients 
must be overcome in the same manner as in tabes dorsal is, which has shown 





Fig. 18. Fig. 19. 

Figs. 18 and 19. — Braces for Treatment op Athetosis. 



excellent effects from FrenkePs compensatory reeducation treatment. In many 
cases I have seen beautiful results from the persistent employment of the fore- 
going methods. 

In the treatment of athetosis great improvement can be obtained. Here 
systematic massage, methodic exercises and afterwards braces which support 
the head and trunk as well as both upper limbs (Figs. 18 and 19) are most 
valuable. 

In the last few years I have attained in these cases very marked improve- 
ment of intelligence and of the speech disturbances by methodic instruction 
in speech. 



TREATMENT 569 

In the treatment of cerebral hemiplegia the orthopedist has thus far 
attained but little prominence, for usually, as we have seen, the upper extremi- 
ties are attacked, which as yet he is powerless to cure, and the disturbances of 
the lower extremities are improved without remedial agents. 

However, in recent years we have been able to offer brilliant service in this 
realm. I have obtained the best result in affections of the lower extremity 
by a combined procedure. For the relief of the pes equinus I have employed 
tenotomy of the Achilles tendon, or Bayer's operation; then a splint-socket 
brace (Schienenhtilsenapparat) is applied to which is attached a girdle for 
the waist, which permits an easy correction of the improper position of rota- 
tion of the extremity. In this apparatus an artificial quadriceps is produced 
by means of rubber bands and thereby an artificial musculature which flexes 
the foot dorsally. This apparatus is worn by the children for one to two 
years, at first constantly; later it is removed for thorough massage and gym- 
nastics and especially for active exercises of the quadriceps and the muscles 
of the foot, and abduction of the hip- joint. Very good permanent results are 
thus attained. 

Tendon transplantation is of great value again in this affection. 

Treatment of the spastic phenomena of the upper extremity is most dif- 
ficult. Here, by means of exercises, such as the Frenkel-Leyden compensatory 
reeducation method, such improvement might be secured as to permit the 
fingers in some measure to grasp again. However, the result of any treat- 
ment falls far short of complete restoration. Recently decided advances have 
been made by tendinoplasty. Here also we are now enabled to weaken the 
spastic muscles and to a certain extent transmit the surplus of energy to the 
antagonists. In several cases I have been able to reestablish almost normal 
function in a hand which was previously altogether without power. 



CHOREA MINOR 

By B. Bendix, Berlin 

Synonyms : St. Vitus's Dance; Chorea St. Viti. 

The conception of chorea minor or of St. Vitus's dance (chorea St. Viti), 
which at various periods throughout the centuries was subject to great diver- 
sity because of the manifold modifications of the disease, is to-day controlled 
by a uniform and stable symptom-complex. The idea of a " dance disease/' 
which the physicians of the period of the first historically positive appear- 
ance of chorea minor associated with it, is now maintained only in name 
(^opela: dance). 

The first accurate data of this " dance disease " dates back to 1374 when 
a great epidemic originated in Aix la Chapelle. At that time men and 
women, young and old, wandered through the city in maniacal excitement, 
performing fantastic dances which produced senseless rapture, and from 
which the}*" did not cease until they fell down weakened and exhausted by 
bodily and psychical exertion. This excitement, originating principally from 
religious beliefs, attacked large numbers of the populace, who travelled from 
place to place, from land to land, so that in time the disease prevailed over 
entire Germany and in the countries bounding upon the north. Thus this 
demoniacal epidemic raged in certain regions for nearly two centuries. In 
the sixteenth century the affection appears to have become infrequent. About 
that period the conception of the disease was evidently changed, in that the 
people no longer resorted to unfounded and purposeless storms of dancing, 
but upon the eve of St. John's Day, in the chapels of St. Vitus, 1 they begged 
of their patron saint protection or cure from severe internal affections and 
tortures by orderly dancing which lasted several hours. 

In later times, after the disappearance of the dancing epidemic, not only 
the dance cult was designated as chorea, but also other motiveless movements, 
as jumping, running, and spasmodic contortions of the body, which were fre- 
quently associated with the most varied emotional expressions as sighing, 
crying, laughing, etc. Those movements which we now associate with the 
picture of chorea were even then included. Undoubtedly, during that period 
two quite different affections were combined, namely, hysteria (chorea magna) 
and true St. Vitus's dance (chorea minor). 

i According to Witkowski, St. Vitus's dance does not obtain its name from St. 
Vitus, but from a very prominent Slavic god, Swantewit (St. Vit), in whose worship 
peculiar round dances were performed at the beginning of summer. 

570 



SYMPTOMS 571 

About the middle of the seventeenth century Sydenham, on the basis of 
five cases of his own observation, first clearly differentiated chorea minor 
from the many choreiform diseases. Notwithstanding his accurate and com- 
prehensive description of genuine chorea and his strict limitation, we now 
find both names, chorea minor and chorea major or magna, side by side as 
chorea anglorum and chorea germanorum, without distinction from other 
nervous diseases, and causing frequent confusion and difference of opinion. 
In the year 1844 Wicke, in his " Attempt at a Monograph of the Great St. 
Titus's Dance and of the Involuntary Muscular Movements," helped to clear 
the situation by giving to chorea its definite place in nosology. In this work 
"Wicke defines Sydenham's St. Yitus's dance as " involuntary muscular move- 
ments." In the year 1887 Ziemssen proposed to separate chorea magna from 
chorea minor completely, as he saw no disease sui generis in the former but 
only " the outflow of true psychoses and cerebral affections on the one hand, 
and on the other hysteria and simulation." 

This brief review of the history of St. Titus's dance shows what manifold, 
varying pictures of disease were at times projected under the conception of 
chorea, and what changes have occurred in the course of centuries. 

Therefore, I must particularly emphasize that by chorea minor we are 
to understand, clinically as well as ctiologically, a well-characterized affection, 
sui generis, which has nothing in common with incurable, progressive, degen- 
erative chorea with its peculiar movements; nor is it to be associated with 
the choreic movements of the heterogeneous cerebral affections. At the same 
time it is to be strictly differentiated from the acute paroxysms of hysteria, 
as well as from the lightning-like contractions of paramyoclonus (chorea 
electrica, maladie des tics). 1 

Wollenberg has proposed for genuine or Sydenham's chorea the name 
"infectious chorea." This designation, which accords to St. Yitus's dance an 
infectious nature or toxic origin, appears to be very acceptable, particularly 
upon the basis of recent etiologic observations. Heubner also favors the in- 
fectious standpoint, to which he gave expression in 1901 at the Hamburg 
meeting of Physicians and Naturalists in his article on chorea minor. Solt- 
mann understands by chorea minor — St. Yitus's dance — a psychomotor neuro- 
sis of subacute course and characterized by a disturbance of coordination, by 
which involuntary conjoined movements are added to the movements of the 
will by irradiation of the will impulse, and also regards the peculiar essential 
idiopathic chorea of infancy as an embolic infectious disease or intoxication 
due to the metabolic products of pathogenic bacteria. 

SYMPTOMS 

The movements of chorea minor are involuntary and are characterized 
principally by their interspersion between the voluntary muscular movements. 

i See volume on " Diseases of the Nervous System." 



572 CHOREA MINOR 

These irregular movements are particularly produced and increased by the 
intention of the will. They do not always bear the stamp of actual incon- 
gruity; on the contrary they are frequently the ordinary expressions of emo- 
tion and excitement, although performed involuntarily and constrainedly. AVe 
might say that they are under the influence of psychical irritation, of pas- 
sion, and that occasionally they even contain an element that is somewhat 
theatrical. 

This peculiar disease rarely begins with acute fulminant or prominent 
symptoms; on the contrary, it is usually of slow, gradual onset. Now and 
then there are prodromes, such as moderate loss of appetite and mild diges- 
tive disturbances, frequently also headache, and vertigo. The child is pale. 
These symptoms are not prominent and cause no concern to the parents since 
children who are affected by St. Vitus's dance are, as a rule, constitutionally 
nervous and anemic. Later, however, when the signs become more and more 
prominent, those about the child realize its altered mood. Previously happy, 
friendly, and lovable, the child now begins to show ill-humor, is disobedient, 
peevish, disagrees with its playfellows, and in school is inattentive and dis- 
trait. Illusions, fixed ideas, and loss of memory are mentioned as rare pro- 
dromes of chorea. 

Besides these psychical changes very often there are simultaneous motor 
disturbances. They consist of involuntary muscular movements, especially in 
the trunk, pelvis, shoulders, and hands, and at first in a milder degree in the 
face and limbs. Thus we frequently observe a heedless play of the children 
with their fingers, motiveless shrugging of the shoulders, restless to-and-fro 
movements upon the chair. Stamping with one foot, a somewhat uncertain or 
dragging gait, or slight tremors in the extremities are sometimes noted. 

In contrast to this subacute, gradual onset of chorea minor, very exception- 
ally there is a more acute appearance of the symptoms. In such cases slight 
fever, herpes labialis, and albuminuria may also occur. 

Gradually the initial symptoms become aggravated. The slight early con- 
tractions of the face and the lightning-like movements of the eyelids and angle 
of the mouth are more intense and more frequent. The shoulders and the 
upper arm are thrust forward and inward, the fingers are seldom at rest but 
perform the most varied movements of extension, flexion, spreading, and grasp- 
ing. The child plays with its fingers continually. The gait is spasmodic, 
stumbling, stamping, uncertain, waddling. The head is turned to and fro, 
the trunk is rotated or moved up and down. Briefly, there is a general 
unrest of the entire external musculature of the body. These involuntary but 
usually coordinated actions are not spontaneous but occur between intended 
movements and are therefore usually much more disagreeable to the child. 
The unrest and haste increase to such an extent that the child is finally inca- 
pable of performing any intended movement without interference of these 
involuntary coordinated movements. An exact analysis of these choreic con- 
tractions shows, as Heubner indicated years ago, that we are dealing less with 
movements which express impulses of the will than with movements of emo- 



SYMPTOMS 573 

tion and excitement. " They are therefore complicated movements which arise 
in St. Vitus's dance from the pathologic irritation." As examples of these 
emotional contractions we frequently observe a peculiar distortion of the mouth 
which expresses irony, shrugging of the shoulders as a sign of indifference, or 
actions of anger, superiority, helplessness, or uncertainty. Soltmann, in his 
monograph in Gerhardt's " Handbook of Diseases of Children," which appeared 
in 1880, called attention to " these rapidly changing, bizarre movements, par- 
ticularly of the face, which vary in intensity and extent and denote at one 
time pleasure and joy, at other times sorrow and care, anger or fear, and at the 
same time, from the rapidity of their change, usually produce a ludicrous 
effect." 

In well-developed chorea the internal muscles also are involved in the 
unrest. The child has difficulty in speaking correctly, it stammers, pauses in 
the midst of a sentence, and, in consequence of disturbing conjoined move- 
ments of the tongue and lips, the attempts to produce an intended word may be 
ineffectual for a considerable time. Deglutition is often difficult. Fluids 
regurgitate through the nose or find their way into the larynx. Accordingly 
the muscles of the tongue, of the palate, and of the pharynx are affected by the 
disturbance in coordination. The ocular muscles sometimes participate in 
these movements; the eye turns hither and thither, there is transitory strabis- 
mus and diplopia. An involvement of the muscles of respiration, in particular 
the diaphragm, has been noted. The respiration may be irregular, at times 
superficial, again deep and sighing, even spasmodic. Exceptionally a hoarse- 
ness and peculiar barking cough are heard without other symptoms of disease 
of the respiratory organs (chorea laryngea). The heart is sometimes involved, 
the irregular action (arhythmic pulse) being due less perhaps to actual con- 
joined movements of the heart muscle (chorea cordis) than to disturbance of 
circulation caused by muscular spasm. 

These troublesome constrained actions of chorea are most noticeable during 
walking; they also become particularly conspicuous in the manipulations of 
daily life which require either complicated movements or some firmness and 
repose in their performance, as in eating, buttoning clothes, putting on shoes, 
and writing. If the child is asked to protrude the tongue or to spread the 
fingers a tremor is observed instead of the usual steadiness. For writing the 
hand must have more than the ordinary support. The writing is characteris- 
tically changed — it becomes " scribbling." 

Choreic children sometimes perform the so-called " mirror writing." This 
is carried out with the left hand, from right to left, and is only intelligible 
when the page is inverted and held to the light or reflected in a mirror. Ac- 
cording to Soltmann, who regards mirror-writing as " the mirror of a diseased 
soul," this phenomenon does not belong to uncomplicated cases of chorea, but 
occurs in neuropathically predisposed children as an expression of cerebral 
disturbance. 

A characteristic of the symptoms of St. Vitus's dance is that they almost 
always cease during sleep. Cases in which this unrest is particularly marked 



574 CHOREA MINOR 

at night and is absent during the day {chorea nocturna) are extremely 
rare. 

The choreic movements usually are at first confined to one side and com- 
monly in an arm; then the other arm or the leg of the same side is involved, 
and finally they are distributed over the entire body. In some cases the motor 
disturbance remains unilateral (hemi-chorea) . In other instances the move- 
ments are bilateral, but are more prominent on one side. The preference for 
the left side, which is indicated by the statistics of See, Ziemssen and Eulen- 
burg, is not confirmed by exact investigation, since it is found that sometimes 
the left, sometimes the right side, is attacked, regardless of regularity. [In 
the beginning the right side is more frequently affected than the left. — 
Editok.] 

Gowers designates those cases of St. Vitus's dance as chorea paralytica in 
which the prominence of the choreic movements is decidedly less than the high- 
graded motor weakness which appears as a pseudo-paralysis of an extremity. 
This pseudo-paralysis or soft chorea ("limp chorea, West" or chorea mollis) 
is limited to one extremity and most frequently to the hand, or it occurs as a 
paraplegia or hemiplegia, or as a complete muscular relaxation of the entire 
body. Upon the whole chorea is rarely associated with paralysis. In addition 
to Gowers, Todd, West and Olivier, only Oppenheim and Nil Filatow have 
reported such cases. Dependent upon the time of development of the paralysis 
and of the choreic movements the last author differentiates three varieties of 
this form : The paralysis appears before the chorea and, in the course of two 
to six weeks is supplanted by it. The five cases of this group which were 
reported b}^ Gowers were limited to a paralysis of one hand without fever, 
facial paralysis or pain. In the second group the paralysis occurs at the acme 
of the chorea ; its development is rarely sudden, usually requiring several days. 
With an improvement of the debility either the case progresses toward com- 
plete recovery or the choreic movements are renewed. In the third series of 
cases the disease begins with paralysis which remains partial or becomes gen- 
eral, and is at no time associated with actual chorea. The diagnosis of this 
paralysis, as an equivalent of chorea, may be made from the absence of fever 
and pain, but particularly from the presence of slight digital contractions 
which are usually found in the paralyzed limbs of such patients. I have never 
observed this pseudo-paralysis in chorea, and we may assume that in isolated 
cases of this kind there is either an exhaustion of the muscles following the 
spasmodic movements, which have continued for weeks and months, or that 
these are cases of hysterical paralysis. 

The bladder and rectum do not usually present functional disturbances. 
Only in one case of chorea, which was not severe, have I observed involuntary 
evacuation of urine and feces. The digestive functions remain normal. The 
urine as a rule is not altered ; albuminuria is rare. 

Sensory disturbances sometimes occur in addition to motor phenomena. 
According to my experience, cutaneous sensation remains normal in at least 95 
per cent, of the cases. In the remainder there is hyperesthesia, hypesthesia, or 



SYMPTOMS 575 

anesthesia. The sensitiveness to pressure of various spinous processes, men- 
tioned by some authors, can seldom be demonstrated. It appears to be either 
without or in very indifferent relation to the disease itself. Keflex irritability 
is usually unchanged; only the patella tendon reflexes are occasionally in- 
creased. 

Among the general symptoms of chorea there is loss of appetite with conse- 
quent pallor and gradual emaciation. 

The psychical disturbances, already referred to in the prodromal stage, 
dominate the mental condition. As was then stated, the child is moody, dis- 
agreeable, readily angered, apathetic, and disinclined to play. Some patients 
are so extremely irritable that very slight provocation, sometimes a mere glance 
at them, produces the severest choreic movements which may possibly ter- 
minate in actual attacks of mania. 

Sight and hearing remain absolutely intact. The reported disturbances of 
these senses, and perhaps also mydriasis, which has been frequently observed, 
are accidental conditions which have no definite causal connection with the 
disease. 

In the severest cases of St. Vitus's dance the restlessness may become so 
exaggerated that all of the extremities are actually thrown about. The child 
can neither walk nor stand and even when kept in bed the limbs are tossed to 
and fro. The intensity and extent of the choreic movements may attain such 
a degree that the child cannot remain quiet for a moment. The tongue is bit- 
ten, swallowing is impossible, and the administration of food is extremely diffi- 
cult or even impracticable. The will has lost all power over the muscles, which 
are uncontrollable and in such a condition of unrest as to readily disclose why 
the startling names " muscle frenzy " and. " muscle delirium " (folie muscu- 
laire) have been attached to this form of chorea, instead of which Eulenburg 
has proposed the name " muscle anarchy." In these extreme cases the psy- 
chical disturbances are particularly prominent. The temperament varies con- 
stantly, the child wavers between laughing and crying, is distracted, replies 
incorrectly to questions, " even his thoughts run away with him." Sleep is 
restless and terminates in fright and delirium. Hallucinations arise, the 
depression of the mind increases to high-graded confusion which goes hand in 
hand with grave delirium, so that the children alarm their associates by loud 
outcries, such as " Fire ! " " Death is here ! " or " I am a thief ! " True 
maniacal attacks are comparatively rare. 

These psychoses of chorea which run their course under the picture of 
intoxication delirium, such as is observed in the acute infectious diseases, usu- 
ally terminate in a comparatively brief time and only exceptionally lead to 
mental deterioration and idiocy. 

With the appearance of acute intercurrent diseases (scarlatina, measles, 
pneumonia) we occasionally note an arrest of the choreic muscular movements 
which, however, usually reappear with greater intensity after the infectious 
disease has run its course. Inversely the intercurrent affection may cause a 
temporary aggravation of the chorea. For example, Soltmann reports a very 



576 CHOREA MINOR 

mild chorea in a girl aged twelve years, which appeared to run its course with- 
out any disturbance of intelligence. Suddenly, however, with the intercur- 
rence of croupous pneumonia and increased motor disturbance, a severe mani- 
acal delirium arose, which recurred upon three successive evenings and disap- 
peared at the crisis. 

It is an interesting fact, which I have noted repeatedly, that the relapses of 
chorea often terminate with the appearance of puberty. 

COURSE OF THE DISEASE 

The symptoms of chorea usually require three or four weeks for their 
development, continue at their acme for a time, and then disappear as grad- 
ually as they developed. The total duration of the affection is not less than 
two, often six, and occasionally ten to twelve months. Wollenberg has calcu- 
lated, on the basis of a large number of clinical cases in which the time of onset 
could be determined with some certainty, that the affection lasts from ten to 
eleven weeks. Oppenheim estimates the duration as two to three months. Now 
and then the so-called abortive forms (forme fruste) of chorea are observed, 
especially after infectious diseases. These rudimentary types, such as a case 
described by Menko which occurred after varicella, may terminate in recovery 
in fourteen days to four weeks. Mild cases of this kind are in contrast with 
chorea of protracted course, which resists cure even after a year. Cases of the 
latter type usually present very slight motor disturbance, with occasional 
exacerbations, and the patients are for the most part slender, delicate, and 
anemic. The permanent forms of chorea minor, which apparently are never 
cured, must also be mentioned, but these usually develop in later life, and we 
are concerned here particularly with the chorea of childhood. 

The frequent tendency to relapse is characteristic of chorea. Sometimes 
one, two, or three relapses occur in the same patient; or the affection may 
recur every year and disappear, as above mentioned, with the advent of 
puberty. The attacks are not always of the same intensity. On the contrary, 
a severe attack may follow a mild one, or the first attack may be severe and 
those which follow are gradually decreased in severity and duration. 

As a natural consequence of the chronic and long-protracted course a great 
number of cases of this type eventually show nutritive derangements — the 
appetite is lost, the child emaciates, loses weight, and becomes pallid. 

Frequent accompaniments, or, if we prefer to call them so, complications, 
of chorea are acute articular rheumatism and disease of the heart. 

Chorea occurs in the convalescent stage of rheumatism as well as in associa- 
tion with the disease, and both affections may arise simultaneously or the 
choreic movements may precede the attack of rheumatism. The conditions are 
similar in regard to cardiac disease. Chorea and disease of the heart, and 
often also the third, articular rheumatism, may appear almost simultaneously, 
or disease of the heart may precede the choreic affection. Again, the cardiac 
complication may arise as a sequel of chorea. The cardiac phenomena are 



PATHOLOGIC ANATOMY 577 

often quite mild: slight, blowing, systolic murmurs at the apex of the heart, 
occasionally merely an increased action, a somewhat vibrating and prominent 
palpable and visible apex beat with a rough character of the heart sounds. 
Frequently, however, a typical valvular lesion may be demonstrated, some- 
times with distributed cardiac dulness, at other times with normal boundaries 
of the organ. In most cases of true endocarditis there is insufficiency of the 
mitral valve. A simultaneous stenosis is rare. Exceptionally the aortic valve 
may be involved or there may be an affection of the myocardium or of the peri- 
cardium. It is a noteworthy fact that with a relapse of the articular rheu- 
matism there is usually a relapse of the chorea. We will also find that cases of 
chorea are particularly numerous where there is an epidemic outbreak of 
articular rheumatism. The frequent coincidence and the intimate relation of 
disease of the heart, as well as of the joint affection, with choreic movements 
will not be discussed at this point. Whether this coincidence is accidental or 
whether there is a causal connection between these pathologic processes will 
be more fully discussed in the etiology of the disease. 

Choreic nephritis, such as has been described by Thomas and by Laache, 
even with a fatal termination, is extremely rare. 

Hysteria has been described as an actual sequel of chorea, although it is 
very uncommon. Leube and Laache in particular report cases of St. Vitus's 
dance with such an outcome. Among 40 cases Laache was able to confirm this 
relationship twice. That genuine chorea may terminate in epilepsy appears 
doubtful. 

DIAGNOSIS 

On the whole the diagnosis of chorea is easy. Confusion can only arise at 
the outset, and especially when the spasmodic movements are infrequent or 
only partially and feebly developed, thus conveying an impression of " awk- 
wardness " or " wilfulness." At this period the symptoms are frequently re- 
garded by teachers and parents only as bad behavior. Later, when the affec- 
tion has progressed, very little doubt in regard to the condition of the child 
can remain. The characteristic, almost continuous play of the muscles, which 
very often involves the entire musculature of the body, the increased action in 
the performance of voluntary movements, the exaggeration in fixing the por- 
tion of the body affected and even upon a sharp glance at the child, the arrest 
of the movements during sleep, and the intact consciousness leave no doubt as 
to the correct diagnosis. 

PATHOLOGIC ANATOMY 

The autopsy findings in chorea are of such a general nature and offer so 
little that is characteristic of the disease that nothing specific in regard to the 
pathologic process has as yet been found. The anatomic changes involve the 
entire central nervous system — the brain and spinal cord — and exceptionally 
also the peripheral nerves. In a large number of cases the necropsy findings 



578 CHOREA MINOR 

show positively no transformation. Thus, in 84 cases in which an autopsy was 
held, See reported 16 negative findings in the brain and spinal cord, 34 cases 
with changes in the heart and serous membranes, and 32 cases with softening 
and tuberculosis of the brain. In some cases hyperemia of the brain and spinal 
cord and their membranes were demonstrated post mortem (Soltmann, 
Miiller). Other authors have found injection of the blood-vessels and hemor- 
rhages into the ganglion cells (Prichard, West and Dickinson). Capillary 
emboli of the vessels and inflammatory changes around these, especially in the 
thalamus opticus and in the corpus striatum (Broadbent) have frequently been 
demonstrated. Meynert found nuclear proliferation in the central ganglion 
cells, Anton observed white cicatrices in both lenticular nuclei as the residue 
of inflammation, Nauwerk found widely distributed changes, partly inflam- 
matory, partly degenerative, in the central nervous system. Eisenlohr re- 
ported a circumscribed sclerosis in the right lateral cervical cord at the 
autopsy of a girl aged 16 years who had suffered from congenital chorea. 
Elischer demonstrated principally degenerative processes in the peripheral 
nerve trunks. According to Kufrmi the pathologic changes of chronic cho- 
rea consist in the main of a slowly progressive atrophy of the ganglion- 
elements of the motor cortical zone which declares itself by small calcifica- 
tions, simple and pigment atrophy, disappearance of the nerve-cells, etc. These 
changes, when extensive, are found in the spinal cord (gray and white sub- 
stances) and under some circumstances are distributed thence to the peripheral 
nerves and finally also to the muscular regions. 

Although we are justified, as it appears, in assuming from these autopsy 
findings of most variable nature and localization that the cases were not 
always genuine chorea, but severe affections of the central nervous system with 
the symptomatic occurrence of choreic conditions, we may also assume that in a 
clinical picture so well characterized and of like appearance there are definite 
lesions of well localized anatomical foundation in the brain, although further 
investigation is necessary to fully clear up the situation. 

In contrast to this inconstancy of the autopsy findings in the central 
nervous system the pathologic changes which are frequently noted in the heart 
are usually similar. In the acute cases with fatal termination delicate 
deposits, either recent or old, are very often found upon the valves of the 
heart, usually so small that they must be sought, and can be readily removed 
only with the moistened finger or a fine brush. These endocarditic changes 
occur principally in the left heart and upon the mitral valve, more rarely 
upon the aortic valve. 

Since attempts have been made to accurately investigate these endocarditic 
deposits, particularly in a bacteriologic respect, very interesting facts have 
been demonstrated. Upon microscopic examination Naunyn found these 
peculiar brownish-red areas in the deposits upon the mitral valve and upon 
the pia mater to consist of rusty brown threads of bacteria. According to 
the reports of the Halle Clinic (1890), in a case of chorea the bacteriologic 
examination of the waterv excrescences of the mitral valve as well as of the 



ETIOLOGY 579 

brain showed the presence of streptococci, and in another case in which the 
deposits from the valves of the heart, as well as those from the spleen and 
from the brain, were cultivated upon agar the cultures showed a thick short 
rod. According to Sachs, Berkley cultivated the staphylococcus pyogenes 
aureus from the blood of a fatal case of chorea. Pianese obtained a bacillus 
from the cervical cord in a fatal case of chorea which, twenty-four hours after 
inoculation into dogs and rabbits under the dura, produced general convul- 
sions or a tremor limited to certain muscle groups. The animals became 
apathetic, emaciated, and were exceedingly sensitive and irritable. Other 
authors, especially among the Italians (Maragliano, Giuzetti, and others) 
demonstrated staphylococci comparatively often in children who had suc- 
cumbed to rheumatic chorea. In 1899 Wassermann, Westphal and Malkoff 
published a very interesting report concerning the bacillary foundation of 
chorea and its relation to articular rheumatism and to endocarditis. The 
reported case, in a clinical as well as a pathologic respect, bore a conspicu- 
ously infectious character. A few weeks after the onset of an acute attack 
of articular rheumatism the patient was attacked by choreic movements of 
all the muscles of the body, which rapidly increased to the severest intensity 
and were accompanied by paroxysmal attacks of confusion and hallucinations. 
The patient succumbed in severe collapse, and in addition to general hyper- 
emia of the internal organs the autopsy revealed very fine endocarditic depos- 
its upon the mitral valve and a recent parenchymatous nephritis. Wassermann 
succeeded in cultivating a microorganism from the blood of the heart, from 
the endocarditic deposits, from the spleen, and from the brain which, in the 
animal experiment, produced multiple arthritic affections. It was, however, 
impossible to produce by this toxin choreic movements in the animals that had 
been infected. 

From these investigations the conclusion follows that in individuals who 
have succumbed to chorea the most varied bacteria (rods, streptococci, staphylo- 
cocci) are found which may usually be demonstrated simultaneously in the 
blood and brain, in the endocarditic deposits, and in the pathologic products of 
articular rheumatism, and from which articular rheumatism may occasionally 
be produced by inoculation of animals. 

ETIOLOGY 
i. AGE 

Chorea is a disease typical of childhood with a special preference for the 
ages between two and fifteen years. I have not observed chorea in nurslings, 
and the reports of such a condition by Simon, Bourson and Bouchy must be 
accepted with extreme caution. According to Soltmann and Heubner a physi- 
ologic congenital chorea, i. e., from birth, is impossible, as at this time an 
influence of the will is out of the question, therefore an irradiation of the 
impulse of the will cannot occur (Soltmann) and the uncomplicated, prac- 
tised movements which are the expression of emotion are absent in the nursling 



580 



CHOREA MINOR 



(Heubner). From the second to the fifth year chorea is very rare. Only after 
this time do we find the greater number of cases, and particularly between the 
seventh and fifteenth years, when the second dentition, the conclusion of the 
cerebral development, the marked processes of growth, and the onset of 
puberty, and simultaneously the deleterious influence of school life, make great 
demands on the youthful organism. [And both mild and marked attacks of 
acute inflammatory rheumatism are quite frequent. — Editor.] 

2. SEX 

Almost all authors who have observed a large number of cases of chorea 
agree that females are affected to a much greater extent than males. As a 
reason for this conspicuous predisposition perhaps the greater sensitiveness and 
irritability of the nervous system in the female is to be considered. The sus- 
ceptibility of the female for chorea is about three times that of the male. 

Regardless of the early statistics and figures, given in the monographs of 
Soltmann, Eulenburg and Wollenberg, we find in the more recent compilations 
the following facts : 



Name of Author. 


Number of Cases. 


Males. 


Females. 


Koch 

Meyer, H 

Frohlich 

Laache 

Briining 

Rabert 


267 
52 
47 
40 
65 
80 


100—37.45% 
20—38.46 
8—17. 
10—25. 
15—23. 
15—19. 


167—62 . 54% 
32—61.54 
39—83. 
3—75. 
50—77. 
65—81 . 







Therefore the average proportion of those who are attacked by the disease 
is 70-75 per cent, of girls to 25-30 per cent. boys. The wide variation in the 
reports may be due to a difference in the statistical material. For example, 
H. Meyer included only children in his compilation, while other investigators 
included cases which occurred in adults. Again, some of the reports are based 
only on dispensary practice, such as that of Eulenburg, while others combine 
dispensary and hospital cases. Whether coincidence plays a role in the varia- 
tion of the figures, or whether it depends upon the greater severity of the 
clinical cases and hence also upon the greater susceptibility of the female sex, 
cannot be answered. 



3. CLIMATE AND SEASON 

Climate appears to be of secondary importance as regards the frequency of 
chorea. Nevertheless it must be mentioned that, according to the reports of 
physicians who have practised in the Antilles, St. Vitus's dance is an excep- 
tional occurrence in that part of the world. Chorea is also rare in the tropics 
and is unknown in China. On the other hand it is said to be common in Eng- 
land and Forth America. 



ETIOLOGY 581 

As to the influence of season the reports of individual authors do not at 
present permit a definite opinion. Although most writers assume a decreased 
frequency of chorea in the third quarter of the year, reports to the contrary 
are extant. 

4. HEREDITY 

Eulenburg regards the neuropathic predisposition together with certain 
influences of age and special conditions in the organism, as well as a periodic 
increase of this abnormal predisposition, as the important predisposing factor 
in chorea, and Ziemssen believes that the inheritance of a markedly irritable 
condition of the nervous system can very often be established. Nevertheless, 
a careful investigation as to the hereditary neuropathic predisposition of 
choreic children, even within such wide limits as include with chorea various 
mental diseases, hysteria, migraine, nervousness, and alcoholism, finds com- 
paratively few points of support for such views. Koch's researches among 
113 cases of chorea yielded only 10 cases in which disease of the nervous 
system could be demonstrated in the ascendants. Chorea in the immediate 
ascendants has been even less frequently demonstrated. Such an occurrence 
must be regarded as very unusual, since Wollenberg could find chorea in the 
mother only 4 times in 112 cases, and Koch found the condition once in 
113 cases; Eabert once in the mother and 3 times among her brothers and 
sisters; Briining once among brothers and sisters; Frohlich 3 times among 
the children and once in the father. Although these observations are not 
without interest, they by no means justify conclusions, nor do they approach 
the figures of other neuroses which are given as proof of the hereditary 
influence. 

5. SPECIAL PREDISPOSING CAUSES 

Anemic, scrofulous and debilitated children, as well as those who have 
become weakened by acute or chronic diseases and nutritive disturbances, are 
unquestionably affected by chorea more frequently than those who are robust. 
Therefore anemia, chlorotic conditions, exhaustive diseases, rapid growth, im- 
proper nourishment, masturbation, the influence of school and other factors, 
appear to be favorable media for the development of the affection. 

Chorea not uncommonly has a direct connection with acute infectious 
diseases. If we disregard the appearance of chorea after rheumatic affec- 
tions, articular rheumatism, erythema nodosum, torticollis rheumatica, and 
after endocarditis and gonorrhea — their intimate affiliation with one another 
and with chorea has already been emphasized, and will be discussed in the 
pathogenesis of the disease — there are yet quite a number of infections which 
are occasionally succeeded by chorea. Especially do we see the affection arise 
after influenza, scarlatina, measles, and also after diphtheria, purulent inflam- 
mation of the tonsils, e^sipelas, gastric catarrh, enteric fever, vulvo-vaginitis, 
etc. It may be assumed that these diseases, with the exception of the rheu- 



582 CHOREA MINOR 

matic affections, stand in no other relation with chorea than that they reduce 
the resistance of the youthful organism and thereby render it more suscep- 
tible to the " choreogenous poison." 

Intense emotion, fright, anger, punishment, or shame are often the insti- 
gators of the disease (occasionalpredisposing cause). A direct cause cannot 
always be ascertained. 

In the epidemics of choreic movements, such as follow the primary dis- 
ease of individual children in families, schools, or pensions, and which are 
due to imitation and example {chorea imitatoria), we have not a true chorea 
but a hysterical affection. 

Of special interest in the etiology of chorea is its connection with rheu- 
matism. The causal relation of these two diseases was set forth by Bright 
and by See and Roger in the middle of the nineteenth century, and has since 
been confirmed by careful and precise investigation. Notwithstanding the 
fact that the relation of these two diseases has been absolutely denied by 
some authors, the unquestioned material at hand justifies the view that the 
coincidence of both diseases is causal rather than accidental. If the proof 
for this assumption is not evident in all of the statistics their lack of uni- 
formity is due mainly to the fact that some authors have concerned them- 
selves only with the question, how frequently chorea has followed an attack 
of articular rheumatism, and have not extended their investigations far 
enough to determine how often rheumatism has developed in later life upon 
the basis of chorea. These investigations were natural, as it is a well-known 
fact that chorea commonly occurs during childhood, while rheumatism is 
a disease of adults. [This latter assertion is modified below, as it should 
be. — Editor.] The variation in statistics also depends upon whether the 
rheumatic basis was limited to true articular rheumatism, or whether even 
vague, tearing pains have been included, as well as torticollis, erythema 
nodosum, erythema exudativum multiforme, gonorrhea, etc. From the recent 
statistics I quote the following figures: Wollenberg found in the hospital 58 
per cent, and in the out-patient department 28.1 per cent, of cases of rheu- 
matism following chorea, therefore an average of 33 per cent. Koch has 
found a causal relation of the two diseases only in 18.91 per cent, of his 
cases. Briining determined their connection in 13.84 per cent., Heubner in 
40 per cent., Frohlich in 31.9 per cent., and Rabert in 28.75 per cent. In 
the Children's Clinic in Basel (Hagenbach) the material was quite different. 
These observations were made by Heinrich Meyer and are of special interest 
for the reason that they include children only, and for the further reason 
that Meyer traced the later course of the cases of chorea, that is, the cases 
that were followed by cardiac and rheumatic affections. Very interesting 
facts were elicited by this painstaking process, namely, that many choreic 
patients who previously did not show the slightest indication of rheumatic 
symptoms were attacked in later life by disease of the heart or by 
rheumatism. 

In 80 per cent, of Meyer's cases a rheumatic (infectious) basis of the 



ETIOLOGY 583 

chorea was established. Other causes played only a predisposing or occa- 
sional role. The rheumatic basis, according to this author, lies in the fol- 
lowing facts : 

(a) Chorea is the occasional equivalent for a polyarthritic attack or, 
after articular rheumatism, takes the place of a relapse. 

(b) Simultaneously with chorea other rheumatic manifestations appear in 
the endocardium, in the joints, and among the general symptoms. 

(c) In individuals predisposed to true rheumatism chorea may introduce 
the rheumatic affection. 

(d) In times of the epidemic appearance of articular rheumatism chorea 
occurs much more frequently. 

(e) Certain cases of chorea respond to antirheumatic treatment. 

In addition to Meyer's investigations I must mention those interesting 
observations which relate to the development of chorea after diseases of the 
same or a very close bacterial etiology, and particularly after gonorrhea, 
vulvo-vaginitis, angina lacunaris, and the oft-mentioned erythema nodosum 
and erythema exudativum multiforme. According to these observations and 
well-established facts we probably have in chorea, with its peculiar and, within 
certain limits, always constant picture, and with its typical course, a true 
infectious disease. In support of this view, aside from the facts already 
mentioned by Meyer under (d) and (e), is the occasional introduction of 
chorea by prodromes and the slight rise of temperature, as in other infec- 
tious diseases, and further, the appearance of an infectious endocarditis and 
nephritis. The tendency of chorea to relapse reminds us of such infections 
as influenza, erysipelas, and pneumonia, and the preference for childhood 
also finds an analogon in the acute exanthemata. The autopsy reveals the 
evidences of an acute infectious disease : General acute hyperemia of the 
internal organs, frequent and very minute endocarditic deposits which are 
readily overlooked, as well as recent parenchymatous nephritis. Not least is 
the bacteriologic finding in the blood, in the joints, in the valves of the 
heart, and in the brain, which has been reported more and more frequently 
in the last decade as an infectious cause of chorea. The investigations of 
Westphal and Wassermann show that postrheumatic chorea is in all proba- 
bility of infectious origin, especially as both of these authors demonstrated 
in a positive case of chorea postrheumatica, which terminated fatally, a 
streptococcus which in the animal experiment produced a multiple arthritic 
affection. 

Therefore we will probably adopt the same conception of chorea, which 
Heubner has recently again set forth, and consider the etiology of the affec- 
tion more from a general infectious standpoint, in that we do not look upon 
rheumatism as the cause of chorea but assume that " chorea is coordinated 
with polyarthritis and carditis and is the infantile rheumatic equivalent of 
the disease." 



584 CHOREA MINOR 



PATHOGENESIS 

From the foregoing the pathogenesis of chorea may be summarized as 
follows: Chorea belongs to the group of general infectious diseases. The 
affection is either due to a peculiar, definite, choreogenous poison or, more 
likely, may be produced by several entirely different noxae, infections, or 
toxins, which individually give rise to the same clinical picture. According 
to the bacteriologic investigations of the last decades, the view that the bac- 
teria or toxins which appear in chorea, endocarditis, and articular rheuma- 
tism are identical, is almost undoubted. The psychic alterations are only of 
predisposing or occasional moment in the development of chorea in so far 
as sudden fright, or the like, produces a point of lessened resistance in the 
nervous system, and thereby facilitates the invasion of the infectious agent, 
or the development and conditions of growth of a microorganism which 
exists normally in the body or has gained entrance thereto. 

Further, in this picture and course of essential chorea, which to a certain 
extent is invariable, we may assume that " the toxin which has been trans- 
ported to the central nervous system and slowly increases there, but which 
gradually becomes attenuated, exhausted or excreted," always produces the 
same changes in definite nervous centers. Usually the exclusive motor irri- 
tative phenomena and the psychical disturbances in the cerebrum, that is, 
the cortico-muscular conduction tract, may be regarded as the principal point 
of localization of the choreic process. That the infectious virus acts only 
upon a definite group of ganglion cells is a quality which it possesses in 
common with the poisons of tetanus and malaria, and with other specific 
toxins. 

According to Soltmann idiopathic chorea is due also to infectious noxae 
and for the most part to the poisons which give rise to rheumatism. This 
author regards the endocardium as the primary focus of the disease from 
which minute particles are loosened and transported by the circulation to 
the cortex of the brain, where they obstruct the tract of volition. The 
impulse is irradiated into improper channels and, when the innervation for 
movement is insufficient and does not occur at the proper time, it produces 
a conjoint action. 

PROGNOSIS 

The prognosis of chorea may in general be regarded as favorable, but 
care must be taken not to calculate too short a duration. According to the 
last 77 cases reported from Heubner's clinic the average length of the dis- 
ease is 44.3 days. The frequent relapses are also to be considered, which, 
however, usually cease upon the appearance of puberty. Although acute 
intercurrent diseases sometimes cause a sudden arrest of chorea it should be 
remembered that just as often a renewal of the choreic process arises after 
the disappearance of the acute malady. Severe complications, as affections 



TREATMENT 585 

of the brain and pneumonia, as well as the simultaneous appearance of 
arthritic disease and involvement of the heart, render the prognosis more 
grave. 

Death from chorea is exceedingly rare in childhood. Soltmann found 
this termination in barely 2 per cent, of the cases, and Bruning, who recently 
reported a compilation of 65 cases of chorea from Soltinamrs Children's 
Hospital in Leipsic, showed a mortality of 3.1 per cent. Of the two fatal 
cases one was moribund at the time of admission to the hospital, so that if 
this case were excluded the mortality would be only 2 per cent. Death is 
usually not due to chorea itself but occurs mostly from complications on the 
part of the heart. Exceptionally acute nephritis is the cause of the fatal 
termination. In the severe cases death may result from exhaustion and is 
then usually preceded for some time by an extraordinary increase of the 
choreic movements together with severe psychical alteration, delirium and 
confusion, which finally give way to coma (Charcot's etat de mal choreique). 

TREATMENT 

In view of our conception of chorea as an infectious disease we must 
agree that even in the mildest cases, and especially in those of recent appear- 
ance, prolonged rest in bed is indicated. This should be continued at least 
until the choreic movements of the muscles decrease. If there is severe 
jactitation the side of the bed must be padded with pillows to protect the 
child from injury. Sweating should, if possible, be produced, as in the treat- 
ment of the acute infectious diseases. In the first eight to ten days of the 
disease, after a warm bath, or even without this procedure, the patient is 
completely enveloped in a wet or dry pack. After the outbreak of perspira- 
tion the child is kept in this state from one-half to one hour. If a profuse 
outbreak of sweat is not produced by this simple measure, even when rein- 
forced by hot drinks such as lemonade or tea, a dose of pilocarpin (0.005- 
0.01) should be administered by the mouth. After sweating, the child is 
dried, rubbed, clothed with warm material, and left alone. If no positive 
success is noted after eight or ten days the treatment should be abandoned, 
as no results will be attained from its longer use. In some cases the quiet- 
ing influence of such measures after a very short period is astonishing. 

Besides rest of the body we must have mental quietude. Excitement is 
to be prevented, as emotional irritation has a great influence on the dispo- 
sition and psychical condition of the patient. The child should be enter- 
tained, but the mind and body must not be taxed and exhausted. The mother 
or a good nurse is the proper companion for the child. Brothers, sisters, 
and playmates are to be kept away. Choreic children should not attend 
school; in the first place they suffer from the necessary discipline of the 
school, and secondly, the spasmodic movements, particularly the grimaces, 
expose them to teasing and ridicule and at the same time opportunity is 
furnished for imitation and for the development of hysterical imitative chorea 



586 CHOREA MINOR 

in others who are of a nervous temperament. Attempts to overcome the 
malady by threats or punishment are altogether wrong as chorea is not to 
be influenced by the will. Admittance to a hospital or similar institution I 
believe to be necessary only in the severe cases or where the home conditions 
are inadequate for proper treatment. 

The diet should be non-stimulating. Spices, alcohol, tea, and coffee are 
forbidden. The food should be abundant, as the choreic patient, " as a work- 
ing person " so to speak, has a great nutritive requirement. In severe cases, 
where there is difficulty in swallowing, nourishment by means of the stomach 
tube may be necessary. 

In the further course of the disease daily outdoor exercise in good weather, 
or a residence in large, airy rooms is necessary. 

Lukewarm baths and lukewarm ablutions of the entire body are always 
useful. Pick and Kraus report favorable results in the treatment of chorea 
from massage and passive movements gradually increased. Schilling advises 
treatment by suggestion. 

All other treatment of chorea is by means of drugs. At the onset and 
particularly when the affection is combined with rheumatic symptoms and 
fever, the salicylates, antipyrin, analgen, exalgin, or other derivatives of the 
aromatic series are in place. 

Favorable results are usually attained from the various preparations of 
arsenic, which has been employed from ancient times in the treatment of 
chorea. I employ Fowler's solution, in exact dosage, beginning with one 
drop three times a day, and after a few days gradually increasing the dose 
to four, six, or twelve drops, then descending in like manner to the original 
dose. The following mixture is given on a full stomach: 

IJ Solut. arsenical. Fowleri gtt. xxx (to lx-cxx) 

Sirup, simpl 30.0 

Aq. dest. ad 300.0 

M. Sig. : Ten grams three times daily. 

Or in pill form: 

^ Acid, arsenicos 0.01 

Mucil. gumm. arab 0.5 

Pulv. rad. liquirit 2.0 

M. f. pilul. No. XX. 

M. Sig. : One or two pills three times daily. 

Ml Filatow (Klinische Vorlesungen iiber Kinderkrankheiten, 1901), fol- 
lowing Comby, employs arsenious acid in the solution of 1 to 1,000 : 

^ Acid, arsenicos 0.1 

Aq. dest 100.0 

M. Sig.: On the first day one-half teaspoonful (4-6 years) or one tea- 
spoonful (10-12 years). 



TREATMENT 587 

In the next seven days the dose is increased daily by the original quan- 
tity, and then decreased in the same proportion. 

In the severe forms of chorea large doses of the bromids are advantageous 
(3-5 gm. daily) : 

R Nair. bromat. ) __ 

r 4 u \ aa 10.0 

Ammon. bromat. j 

Sirup, papav 5.0 

Aq. dest. ad 200.0 

M. Sig. : Ten grams three times daily (10-15 years). 

To give the patient rest for several hours enemata of chloral hydrate are 
employed (1.0-1.5 per dose according to age), or sulphonal (0.3 gm. for 
children six years of age or 0.5 gm. for children of ten years), given at bed- 
time in powder form and in gruel, is a serviceable hypnotic. Morphin is 
not advisable. 

If the child is pale and weak, iron or quinin is to be administered in 
combination with arsenic. 

IJ Solut. arsenical. Fowleri 3.0 

Tinct. quin. composit. > __ 
Tinct. ferr. pomat. J 

M. Sig. : Ten to thirty drops three times a day. 

If anemia is profound, iron preparations are useful, alone or in com- 
bination with quinin (Ferr. saccharat. oxydat. solub., 0.5-1 gm. three times 
daily, or Ferr. carb. sacch., as much as will stay on the tip of a knife, or 
Quin. ferro-citric, 0.1-0.2 in powder, pill, or solution). 

ty Extract, digital 0.18 

Quin. sulph 0.3 

Massas pilul. Blaudii 8.0 

M. f. pilul. No. LX. 
M. Sig.: One or two pills three times daily (Soltmann). 
Or 

^ Quin. sulph 0.15 

Ferr. carb. oxydat 0.5 

M. f. pulv. tal. dos. XX. 
M. Sig. : One powder three times a day. 

$ Ferr. sulph. ) g Q 

Kal. carbon. ) 

Mucil. tragac. q. s. 

M. f. pilul. No. L. 
M. Sig. : Two to five pills twice daily. 
Or 

^ Ferratin 2.0-4.0 

Saccharin 25.0 

M. Sig.: One-half teaspoonful twice daily (Ml Filatow). 



588 CHOREA MINOR 

Arsenical waters containing iron (Roncegno and Levico) are serviceable 
if the treatment is prolonged, and especially during convalescence. 

The anemia should also be influenced by the food and to that end fresh 
meat, meat extracts, fresh vegetables, especially spinach, as well as albumose 
preparations and malt are indicated. 

During convalescence from this exhausting disease the debilitated and 
anemic children require a residence in the mountains or country, mild hydro- 
therapy, stimulation of the appetite, and good food. 

[The best remedy for mild and severe cases is arsenic. The liquor potassii 
arsenitis should be given three times a day after meals, amply diluted in 
water. The doses should be slightly increased from day to day and may 
reach the double or threefold quantity; for instance J ounce may be mixed 
with one ounce of water. The initial dose of 6 drops may be 7 drops, 8 
drops, 9 drops, etc., up to 15 or 20 or more, a drop to be added every con- 
secutive day. If symptoms of overdosing should appear, edema of the eye- 
lids or face, intestinal disturbance, eruptions, no increase would be allowed, 
or the dose slightly diminished. When no effect is attained, the dose was 
too small. Medicines must be given for effect, or not at all. 

A dose of antipyrin with a bromid, or codein will secure a good night's 
rest. 

"When chorea persists in the night, rest must be enforced by chloral and 
a bromid. Bad cases must be made to sleep from 14 to 18 hours daily. 

Very violent and sudden cases which are complicated with pain on pres- 
sure over the cervical part of the spine, and elevation of temperature, require 
ergot (and a brisk purgative, magnesium sulphate) until the symptoms of 
spinal congestion are quieted. — Editor.] 



PNEUMONIA OF CHILDREN AND ITS 
TREATMENT 

By E. Henoch, Dresden 

Pediatrics should be the last subject of clinical study. Therefore, in 
describing the various forms of infantile pulmonary inflammation, which 
have many signs and symptoms in common with the disease in adults, I am 
justified in the omission of several points which I take for granted are well 
known, and shall merely touch upon others. I shall not present a dogmatic 
description, but will attempt to fulfill my object in a more clinical manner. 

We will begin with an examination of two patients. The first is a boy, 
aged 6 years, who has been in the hospital about three days. The rapid 
movements of the ala nasi and, more so, the auxiliary respiratory muscles 
of the thorax and of the diaphragm, reveal a serious affection of the organs 
of respiration. There is decided fever (39°-40° C.— 102.2°-104° F.), the 
pulse is full and rapid (136 per minute), although not to the extent that 
would be expected from the increased respirations (40 per minute). The 
occasional dry cough produces a painful contraction of the facial muscles, 
and upon the cheeks there is decided flushing. No sputum can be obtained. 
Upon physical examination we find a normal condition of the heart, but upon 
the right side posteriorly from the spina scapulae to the base, and limited 
by the axillary line, there is marked dulness upon percussion, and bronchial 
respiration and bronchophony over the same area ; the remainder of the thorax 
presents nothing abnormal. 

Examination of the second patient, a child of 3 years, who has been 
seriously ill for about eight days, reveals the same general symptoms — high 
fever, cough and dyspnea. Upon closer observation, however, it is noted 
that the cough is much more constant and tormenting, and the dyspnea 
more pronounced than in the first case. The respirations occasionally increase 
to 60 per minute, while the pulse is small and at the rate of 140 per minute ; 
all of the auxiliary muscles of respiration are active, and each expiration is 
accompanied by a short moaning sound which is audible even during slum- 
ber. The face is pale and denotes suffering. Percussion reveals slight bilat- 
eral dulness at the base posteriorly, and upon auscultation there are fine, 
ringing rales from the middle to the base at the back which completely 
obliterate the normal respiratory murmur ; at other areas of the thorax many 
rales may be heard laterally and anteriorly. 

It is my purpose to describe only the principal features of the disease 

589 



590 PNEUMONIA OF CHILDREN AND ITS TREATMENT 

and to omit the secondary phenomena, since only the former will give us a 
clear insight of the nature of the affection. It is obvious that in botli the 
foregoing cases we are dealing with an acute inflammatory affection of the 
lungs, but two essentially different forms are presented. In the first patient 
we are concerned with a unilateral affection limited to the pulmonary tissue 
of the right lower lobe; in the second case there is a bilateral inflammation 
especially implicating the finer and finest bronchial twigs of both lower lobes. 
These two principal types, which are known as "primary or fibrinous 'pneu- 
monia " and " catarrhal or broncho-pneumonia," will now be considered in 
detail. The latter disease is far more common in childhood; nevertheless, 
among 123 clinical cases of fibrinous pneumonia there were 26 whose ages 
ranged between 6 months and 3 years. 

PATHOLOGICAL ANATOMY 

First a brief description of the anatomico-pathological lesions is neces- 
sary. The essential difference is in the distribution of the inflammation, 
which, in broncho-pneumonia, arises always in the branchings of the trachea, 
thence invading the finest bronchial tubes and the pulmonary alveoli; while 
primary or fibrinous pneumonia does not require this propagation from the 
bronchi but begins suddenly, implicating a large or smaller area of the 
parenchyma of the lung, and producing consolidation by means of a coag- 
ulable exudate. It is, therefore, evident that broncho-pneumonia is intro- 
duced by a more or less extensive catarrh; while the primary form, provided 
there is not an accidental preceding catarrh, begins suddenly in the midst of 
health. For this reason it is necessary to guard against broncho-pneumonia 
in children who suffer from bronchial catarrh, therefore in all infantile affec- 
tions, especially measles, influenza, and whooping-cough, in which this con- 
dition is present. Fibrinous pneumonia is by no means infrequent in the 
course of these diseases — a fact of which I shall make mention later — but it 
is much less common than broncho-pneumonia, which is the most frequent 
cause of death in the course of these infections. This mortality is greater 
the younger the child; for it is a fact, although unexplained, that chil- 
dren in the first years of life show a special predisposition to this spread 
of the bronchial catarrh to the finest bronchial twigs, which is less evi- 
dent as the age increases, so that, apart from cases of an infectious na- 
ture, the typical broncho-pneumonia which is observed daily in young children 
is very rare in adults, and only becomes frequent again in the aged and 
senile. 

The anatomical form, in which both diseases appear, may be explained 
by this difference of development. Primary pneumonia at once attacks a 
large portion of the lungs — an entire lobe, or even a greater area — and trans- 
forms it, usually with great rapidity, into a compact, airless, " hepatized " 
mass, while the remainder of the lungs may be exempt. Broncho-pneumonia, 
however, following the course of the medium and small bronchi, distributes 



PATHOLOGICAL ANATOMY 591 

itself to the pulmonary alveoli, and, primarily, to those in relation to the 
bronchioles already attacked by the inflammation. At first no lobar con- 
tinuous consolidation occurs, as in the primary form, but a lobular one, so 
that only the lobules of the lung in relation to the bronchioles implicated 
are consolidated, in the form of coarse foci of a reddish brown or gray color, 
varying in size from that of peas and beans to hazel-nuts, which may be seen 
and felt within the parenchyma, which may still contain air. For this rea- 
son the older physicians designated this form " lobular pneumonia " and 
regarded it as characteristic of the first years of life. Very often, however, 
this does not terminate the condition, for the more numerous the bronchioles 
which are implicated in the inflammation, the more alveoli and correspond- 
ingly the more lobules are involved in the process. The hyperemic inter- 
spaces, which at first contain air, gradually become smaller, and the diseased 
lobules approximate one another and by confluence may finally lead to 
extensive, wedge-shaped consolidations which are commonly found at both 
lower lobes, ascending from the base. Such a condition may also be present 
in the upper lobes, even upon that portion of the left upper lobe adjacent to 
the pericardium. This extensive consolidation, designated by the French 
" pneumonie lobulaire generalisee" may give rise to perplexity in diagnosis, 
provided such a form of development is unfamiliar to the physician, for the 
physical signs show great similarity to primary pneumonia. 

In addition to the differences between these two types of pneumonia which 
have already been described, it was formerly supposed that there were varia- 
tions in the nature of the inflammatory product. It was assumed that in 
primary pneumonia the alveoli were filled with a solid mass consisting largely 
of coagulated fibrin and blood-corpuscles, while in broncho-pneumonia the 
contents were almost entirely fatty epithelial cells and pus-corpuscles. This 
view is no longer tenable. Eecent investigations (Steffen, Steiner, Dama- 
schino, Cadet de Gassicourt and others) show that fibrin, although in less 
amount, is also contained in the alveoli of the broncho-pneumonic foci. But 
to this must be added the important fact that, besides the specific organisms 
which commonly give rise to primary pneumonia, Frankel-Weichselbaum's 
diplococci have also been demonstrated in broncho-pneumonic foci. Thus 
we are forced to the conclusion that, in both forms of pneumonia, the same 
infectious elements play a role, that there is scarcely an essential difference, 
but the preceding or non-implication of the bronchi has such an important 
effect upon the course and form of the disease that, where a diffuse bronchial 
catarrh already exists, the additional effect of the pneumococci impresses the 
stamp of inflammation, producing broncho-pneumonia. This view is favored 
by my observation of a few cases in which a fibrinous pneumonia of an entire 
lobe was found upon one side, and a simultaneous bronchitis with lobular 
foci upon the other. Whether we regard the pneumococci as having a spe- 
cific action, or that they only play a role of simple generators of inflamma- 
tion, like many other bacteria, I believe to be immaterial. No matter how 
these conditions may be regarded in the future, it is certain that in most 



592 PNEUMONIA OF CHILDREN AND ITS TREATMENT 

cases, at least, the clinical differences are sufficient to permit of a positive 
differentiation of the two forms. 

CLINICAL PICTURE 

Primary pneumonia attacks children and adults alike, in the midst of 
complete health, as a true infectious disease with sudden high fever, fre- 
quently associated with vomiting, but often without initial chill, particularly 
in infants; the temperature rises rapidly to 40° C. (104° F.) and above (in 
one case I noted a temperature of 41.2° C. (106.2° F.) on the first evening), 
and in combination with the general signs of illness — somnolence, restless- 
ness, mild delirium — it denotes a serious affection. However, in the first 
days the respiratory symptoms and even cough may be absent, and the physi- 
cian is often puzzled over the diagnosis. Many other diseases, particularly 
scarlatina, show a similar onset, and the slight cutaneous erythema which, 
as a rule, is only partial, and a hyperemia and swelling of the gums and 
pharynx, often lead us to suspect this infectious disease. This uncertainty 
continues, unfortunately for the physician and parents, so long as the exam- 
ination of the thorax reveals nothing abnormal, but usually not longer than 
from thirty-six to forty-eight hours; occasionally, however, a correct diag- 
nosis cannot be made for several days, and in one of my cases the disease 
could not be determined even up to the crisis on the sixth day. Under such 
circumstances, as has been my experience, we think of enteric fever, menin- 
gitis, even acute osteomyelitis. Many children complain of marked hyper- 
esthesia of the skin which renders the slightest pressure painful and which 
is liable to cause diagnostic errors. The nature of the respiration should be 
particularly observed. Although cough and dyspnea may be absent, the res- 
piration is conspicuously short and much increased in comparison to the 
pulse frequency, and the expiration is often accompanied by brief moaning. 
If there is also a diminution of the vesicular respiration in some portion of 
the lung, and, in addition, even a scant crepitation which at most can only 
be heard upon deep inspiration, we may be pretty positive of our diagnosis. 
A differentiation may be made more difficult by the appearance, simulta- 
neously with the onset of the disease, of serious cerebral symptoms, such as 
deep somnolence, marked delirium, temporary unconsciousness, and even 
severe, repeated convulsions, examples of which I have detailed in another 
article. 1 As to the reason for these disquieting symptoms, which in fact 
greatly resemble meningitis (pneumonie cerebrale of the French), opinions 
are divided. High temperature alone can scarcely be regarded as the cause; 
but even the effect of pneumococci and their toxins upon the brain cannot 
be considered, because the severe cerebral symptoms are only introductory 
phenomena which disappear with the manifestation of distinct pulmonary 
symptoms (dulness upon percussion and bronchial respiration) and have no 
influence upon the further favorable course of the disease. Such cases are 

i Vorlesungen iiber Kinderkrankheiten, 1899, 10 AufL, p. 382. 



CLINICAL PICTURE 593 

by no means rare in children and many a fortunate case of " cured menin- 
gitis " may have been a mistaken pneumonia. Here I naturally disregard 
those cases wherein there is a complication of cerebrospinal meningitis with 
pneumonia — a condition which will not be discussed here. 

Broncho-pneumonia. — In broncho-pneumonia the initial symptoms show 
a great contrast to this violent onset. Usually a more or less prolonged 
catarrhal stage precedes the actual affection, which, if neglected, will only 
too frequently have serious results, particularly among the poor. In numer- 
ous cases, however, especially in small, badly ventilated and crowded rooms, 
and in hospitals, the propagation of the catarrh to the smaller bronchi and 
to the alveoli, which cannot be prevented, is only to be explained by the 
inhalation of bacteria, and it is here we find the greatest number of children 
who are affected with, and perish from, broncho-pneumonia. According to 
my experience the autopsy of most young children who succumb from vari- 
ous affections in hospitals, foundling asylums, etc., demonstrates a more or 
less extensive broncho-pneumonic foci in the lungs. The infectious nature of 
this complication may be concluded from its enormous frequency. Eecently, 
and particularly in France, it has been maintained that the infectious organ- 
isms (streptococci and pneumococci) not only reach the lungs by means of 
the inspired air, but also that coli and other bacteria find their way from 
the intestinal canal through the lymph- and blood-channels into the organs of 
respiration and may produce broncho-pneumonia. This view, which is based 
upon the frequent simultaneous existence of enteric and broncho-pneumonic 
processes, has not yet been proven, and, therefore, is problematic, because the 
presence in the lungs of the aforesaid intestinal bacteria may be due to agonal 
and postmortem migration and increase, as has been demonstrated. 

With the gradual distribution of the inflammation to the finer bronchi 
and beyond, and in addition to the catarrhal symptoms already present, there 
is a constant slow or rapid increase of the pneumonia, not with high and 
continued fever, as in tho primary form, but with pyrexia which shows 
marked remission in the morning hours and in the evening may range from 
39.5° to 40° C. (103.1° to 104° F.) ; dyspnea increases, and the cough becomes 
more frequent and more tormenting. These symptoms are due to the bron- 
chitis, which distributes itself to the deeper parts, giving rise to marked 
irritating cough, and are much more dependent on the decreased function of 
the larger respiratory area than is the case in the limited primary form. It 
must always be remembered that in broncho-pneumonia we are dealing with 
a bilateral affection which consists of more or less numerous lobular foci with 
a constant tendency to approximation, and in which even the intervening 
parenchyma has become hyperemic and shows serous infiltration. But to this 
is added another important element: the muco-purulent exudation in the 
small bronchi, which impedes the entrance of air to the affected pulmonary 
areas, and, together with the constantly decreasing inspiratory power, finally 
occludes them. This explains the formation of numerous atelectatic foci in 
broncho-pneumonic lungs. In addition, the frequent respirations (I have 
39 



594 PNEUMONIA OF CHILDREN AND ITS TREATMENT 

counted 80 in the minute) and the labor of the auxiliary respiratory muscles 
(ala nasi, shoulders, etc.) are much more intense and are accompanied by a 
constant moaning sound which has been aptly termed by a French author 
" I 'enfant crache son expiration" I attach great importance to this symptom 
because it has indicated the correct diagnosis often prior to the examination. 
The changed relation of the respiration to the pulse frequency is also impor- 
tant. Normally these are in the proportion of about 1 to 3J, while in the 
present condition there are 50 or 60 respirations to 120 or 140 beats of the 
pulse. That with such an important and extensive limitation of the respira- 
tory surface stasis occurs in the venous system, as well as cyanosis and even 
slight edema, is readily comprehensible. 

Nevertheless, we must not expect to find in all cases of this kind at once, 
upon physical examination, the distinct signs of consolidation of the paren- 
chyma. So long as the lobular foci are insular, separated from one another 
by tissue which contains air, the percussion note shows very little change, and 
auscultation reveals only widely distributed, fine, moist rales and here and 
there crepitation, especially upon both posterior surfaces from the spine of the 
scapula to the base of the lungs, but also laterally and anteriorly. Occasionally 
I have been able to note at the onset fine crepitant rales from the left upper 
lobe to the lingula overlying the pericardium. Therefore, we are only capable 
of demonstrating physically a catarrhal bronchitis. But experience has shown 
that, at least until the fourth year of life, this condition never occurs without 
kroneno-pneumonic foci, hence the diagnosis becomes positive. Confirmation 
by physical signs is not possible until the foci become so numerous and conflu- 
ent that there is no longer an air-containing intermediary parenchyma. Only 
then do the physical signs of consolidation, fine crepitant rales in great distri- 
bution, bronchial respiration, and bronchophony become noticeable; finally, 
also, the dulness of the note upon percussion. This method of examination 
should be especially light over those regions which have already been men- 
tioned, as we thus avoid the note of layers which may still contain air. All 
of these physical signs are bilateral, although not always of equal intensity, 
and from this fact alone, quite apart from the rapid, tumultuous onset of 
primary pneumonia, they differ from the unilateral symptoms of consolidation 
which are almost always present in the latter disease. 

COURSE OF THE DISEASE 

The further course differs greatly. The primary form advances with con- 
tinued high fever, the local phenomena remaining about the same to the crisis, 
which occurs usually at the end of a week, although not rarely between the 
third and fifth days. The fever drops temporarily, for example, from 40° to 
38.8° C. (104° to 101.8° F.), again to reach its acme in twelve to twenty-four 
hours. I shall recur to the deviations from this rule. On the other hand, 
broncho-pneumonia shows a protracted course, with a constant, but irregular 
variation of improvement and retrogression. The reason for this fluctuation 



COURSE OF THE DISEASE 595 

is that while a portion of the consolidated pulmonic lobule is undergoing invo- 
lution, the inflammation is extending from the branch of the bronchial tree to 
other alveolar groups, which have thus far been intact, and new lobular foci 
are formed which cause the declining fever to flare up anew. Therefore the 
" regular course with critical defervescence " cannot occur here ; the duration 
is indefinite, often extended from weeks to months, exhausting the strength of 
the child and rendering the prognosis grave. For this reason alone broncho- 
pneumonia is much more serious, especially in infancy, than the primary form, 
which ordinarily shows a favorable course if no serious complications arise. 
Among 153 clinical cases of fibrinous pneumonia I have lost only 8, and of 
these one showed at the autopsy hepatization of the entire right lung, another 
bilateral pneumonia and pericarditis, a third peritonitis, and a fourth multiple 
tuberculosis. If these figures are compared with the great mortality of 
broncho-pneumonia, which is an actual scourge among infants, the difference 
is apparent at once. Probably all physicians will coincide in this, especially 
if they have had an opportunity to observe cases in children's hospitals or to 
practise among the poor. 

Although the foregoing conditions of both forms of pneumonia apply in 
the great majority of cases, they are by no means applicable to all. Here as 
everywhere in the practice of medicine there is " no rule without an exception," 
and it is, therefore, my object next to present a somewhat minute description 
of the variations from the norm. 

There may be a modification of the development of 'primary pneumonia 
in that it may be associated with an already existing acute or chronic bronchial 
catarrh. In cases of this group catarrhal rales may be heard in the bronchi 
throughout the entire course of the disease, in addition to the physical signs 
of consolidation. Critical defervescence does not always occur in cases having 
a favorable termination. Among 160 of my cases crisis occurred 100 times; in 
17 cases there was lysis, while of the remaining 43 cases no positive report 
can be made. In 68 cases the crisis appeared between the sixth and eighth 
days, less frequently it occurred on the fifth or sixth day and even between 
the ninth and eleventh days. There may be cases which present all of the 
symptoms of hroncho-pneumonia and terminate in rapid recovery in a week, 
but they are doubtful, because, as I have stated, primary pneumonia may 
exist simultaneously with bronchial catarrh and thus render the diagnosis un- 
certain. On the other hand, the primary form may run an unusually pro- 
tracted course, as in one of my cases wherein crisis did not occur until the 
seventeenth day. This prolonged defervescence was occasioned by two relapses 
with an afebrile interval of twenty-four hours, the lesion being in the left 
lower lobe. 

The prolonged course in these abnormal cases is usually explained by the 
fact that a pneumonia resembling erysipelas in its development, creeps from its 
original focus to neighboring areas, for example, from the right lower lobe to 
the upper lobe, and thus the physical signs of consolidation at the lower 
portion of the right posterior surface, therefore in the area first attacked, 



596 PNEUMONIA OF CHILDREN AND ITS TREATMENT 

disappear, while in the right axillary space, and finally at the upper lobe 
anteriorly, there is dulness and bronchial respiration. This form, which has 
been designated 'pneumonia migrans, may continue for several weeks, similarly 
as in broncho-pneumonia, the fever declining and rising until crisis finally 
appears. My own cases of this group terminated favorably with a typical crisis 
between the twelfth and fifteenth days, but the outcome is not always so 
fortunate. This variety does not involve the bronchi ; perhaps the condition is 
similar to that of erysipelas, wherein relapse is caused by a progression of the 
bacteria. 

It is probable that to this category of wandering pneumonia belong numer- 
ous cases which present the same characteristics, but in a less marked form 
than those just described, since otherwise their deviation from the typical 
course cannot be satisfactorily explained. As a good example of this variety 
I will relate a case which I saw about the beginning of March, 1901. A 
robust girl, aged 9 years, was attacked at night, while returning from a chil- 
dren's party, with sudden, repeated vomiting, and marked chill followed by 
high temperature, nearly -±0° C. (104:° F.). The fever remained at its acme 
about twenty-four hours and declined in a critical manner below normal. 
Apart from the almost general hyperesthesia of the skin and a systolic murmur 
of the heart, the examination revealed nothing abnormal, therefore the attend- 
ing physician made a diagnosis of influenza with an endocardial complication. 
The next day there was renewed fever, which rose rapidly step-wise, and upon 
the middle of the third day (from the appearance of the chill) it was again 
40° C. (104° F.). That evening I saw the child for the first time and diag- 
nosticated pneumonia of the left lower lobe, the symptoms of which had first 
become manifest to the physician that morning. The systolic murmur could 
nc longer be detected. The fever remained high almost continuously, while 
from the fourth to the fifth day dulness and bronchial respiration progressed 
toward the apex of the lung, proceeding from the origin of attack at the base. 
At the lower portion, however, the physical signs had decreased. In the 
night of the fifth to the sixth day there was crisis with copious sweating, and 
the affection terminated favorably. 

I cannot agree with those physicians who declare such cases to be " influ- 
enza pneumonia " in the absence of positive proof. Quite apart from the fact 
that the pulmonary inflammations which depend upon pneumonia are almost 
always cases of broncho-pneumonia, it is very unlikely that an influenza which 
begins with such an intense fibrinous pneumonia can terminate in complete 
crisis after a course of only five days. On the contrary, I believe that these 
are cases of pneumonia migrans, with a critical defervescence of the first 
attack at the end of twenty-four hours, and upon the following day an upward 
migration with renewed fever which terminates between the fifth and sixth 
days in crisis, therefore unusually early. The systolic murmur (which I did 
not hear) was probably only an accompaniment of the high fever. This case 
reminds us of the type often designated " intermittent pneumonia" which has 
nothing in common with malaria, and belongs to the category of " wandering 



COURSE OF THE DISEASE 597 

pneumonia.'" These pneumonias also, notwithstanding the high fever which 
continues for four or five days, may have entirely latent physical signs, owing 
to the fact that hepatization proceeds gradually from the interior of the lung 
and becomes recognizable only when it reaches the periphery. In two instances 
I only succeeded in demonstrating consolidation by physical signs immediately 
before the crisis, when the fever began to decline. Here the absence of diag- 
nostic symptoms continued for six or seven days and there appeared to be no 
other explanation for this than a progression of the hepatization from the 
center of the lung to the periphery (central pneumonia). 

It must be further noted that occasionally on the first day after the crisis, 
even when the temperature has fallen below normal, there may be a sudden 
rise— 39° to 40° C. (102.2° to 104° F.)— which is a source of great anxiety to 
the physician and parents, but the cause of which I have never fully deter- 
mined. So far as I was able to observe, this sudden pyrexia was always ephem- 
eral; often upon the following day the temperature again became normal and 
remained so. 

Much more rare than a protracted course is a short febrile attack. I have 
seen three undoubted cases of primary pneumonia with crisis upon the third 
day, that is, in the night between the second and third days. In literature 
cases of even a shorter duration are reported, sometimes, in adults, a termina- 
tion at the end of twenty-four hours. These so-called ''abortive pneumonias " 
may actually be identical with the indistinct and varying pathologic pictures 
which the French have described under the name " congestion pulmonaire 
aigue," by which they do not imply actual hepatization but only temporary 
congestion due to extensive hyperemia and serous infiltration of the paren- 
chyma, which, however, rapidly disappears. The anatomical proof for such a 
conception is not given to us by the French physicians and if, instead of this, 
they refer to the rapid recovery, I must quote the following case. 

Max S., aged 11 years and 9 months, was admitted to the hospital upon the 
27th of June with an afebrile bronchial catarrh. Upon the 30th of June sud- 
den high fever developed — 10.5° C. (104.9° F.) — with respirations of 40 per 
minute, a pulse of 138, cough and left-sided pain on respiration; below the left 
scapula respiration was indistinct. On the 1st of July there was dulness and 
bronchial respiration with crepitant rales, temperature 40° to 40.4° C. (104° to 
104.7° F.), respirations 40, great debility at night, sputum decidedly rusty. 
The following morning (beginning of the third day), after profuse sweating 
and good sleep, there was a condition of comfort. Temperature 37° C. 
(98.6° F.), respirations 25, pulse 80. On the kth of July the dulness had 
disappeared; there was only harsh breathing with isolated crepitant rales. 

In this case, which is at the same time a good example of the onset of 
crisis during the night between the second and third days, no expert would 
doubt that he was dealing with an actual pneumonia, particularly as rusty 
sputum was often present, — a rare occurrence in infancy. Nevertheless, the 
physical signs of consolidation had disappeared on the fifth day after the onset 
of the disease. Such a course is very unusual, for, as a rule, at least eight to 



598 PNEUMONIA OF CHILDREN AND ITS TREATMENT 

ten days elapse before evidences of consolidation have completely disappeared. 
If the condition continues for a longer period we must consider that we may 
be dealing with a pleuritic condition, since a complication with pleurisy 
occurs in children as well as in adults. I must also mention that in three 
children I have observed the disappearance of physical signs even before the 
advent of the crisis. Although there was continued high fever — 40.6° C. 
(105.1° F.) — and other pathologic phenomena were still noted, the dulness 
had disappeared and fine crepitation was superseded by mucous rales two or 
three days prior to complete crisis. 

Analogous observations in adults have been reported by Grisolle and Sidlo. 
Whether in these cases a bacterio-toxic influence maintained the fever for some 
days, or whether anatomical changes persisted which were not demonstrable by 
physical examination, cannot be determined. 

PROGNOSIS 

That primary pneumonia offers a much more favorable prognosis than 
broncho-pneumonia, and the reasons therefor, have already been discussed. 
Nevertheless we must never be too positive in our conclusions. We may expect 
a favorable outcome in children previously healthy and with a limited exten- 
sion of the disease, and these cases fortunately preponderate. Among my 160 
cases 153 were affected only in one lobe of the lungs and most frequently the 
lower lobe (the right upper lobe 33 times, the left upper lobe 4 times). Impli- 
cation of the entire lung (which occurred in only 3 instances) and consolida- 
tion of both lower lobes, is rare, and when such a condition occurs the prog- 
nosis is naturally more unfavorable. This is also true when pneumonia 
appears in a child already ill, and particularly when it develops in the course of 
an infectious disease. While the pneumonia which occurs as a complication in 
tuberculosis, measles, influenza, scarlatina, whooping-cough and enteric fever 
is usually the broncho-pneumonic type, other forms may be noted. In most of 
these infectious diseases I have observed cases of fibrinous pneumonia, and this 
condition has often been demonstrated at autopsy. In a child of 12 years, suffer- 
ing from enteric fever, with an almost continuous temperature of 40° C. (104° 
F.) or over, which was not influenced by treatment, the left lung was found to 
be completely consolidated, and in the midst of this thickening, upon the lower 
boundary of the upper lobe, there were two insular foci the size of a bean and 
of a hazelnut. Another case, a boy, aged 4 years, who was attacked by pneu- 
monia during convalscence from a diphtheritic nephritis, succumbed nine 
hours after a fulminant onset of the fever, and the autopsy showed hepatization 
of the entire right lower lobe, with a pale, flaccid heart, which, unfortunately, 
was not examined under the microscoj^e. Such an examination would unques- 
tionably have demonstrated the cause of the rapid and fatal course of this 
very limited pneumonia. 

As has already been stated, pleurisy is very often a complication of 
fibrinous pneumonia in children, just as in adults. In older children this com- 



PROGNOSIS 599 

plication is manifested by pain upon breathing or coughing, or when lying 
upon the affected side, and by physical signs upon palpation and percussion of 
the intercostal spaces. But this complication is of greater importance in 
infancy, since a purulent exudate is much more likely to be present than in 
later years, and this may develop with such rapidity that in five to seven days 
there is a well-marked empyema. In infants the pericardium may be affected 
and a purulent pericarditis has frequently been present of which there were 
no definite signs during life. 

In the foregoing case of typhoid pneumonia the autopsy revealed two 
sequestrated foci in the midst of the consolidated parenchyma. They were 
readily distinguished from the surrounding brownish red hepatization by their 
yellowish tint, demarcated by a dark red line. If the case had continued 
longer there would undoubtedly have been either a gangrenous necrosis or an 
abscess in these foci, — two methods of termination which, at least in my 
experience, are exceedingly rare in children otherwise healthy. Larger ab- 
scesses, which may be recognized during life, I have noted but twice: in a 
girl of 7 and in another of 11 years. In both patients cure followed the sponta- 
neous expectoration of profuse amounts of pus. It is of interest to note that 
in one of these cases a pneumonia appeared abruptly after the fifth injection 
of 0.001 of tuberculin. The child was not tuberculous, but injections were 
instituted as a test by the wish of the exceedingly anxious parents. However, 
a very instructive proof was furnished of the inflammatory effect of tubercu- 
lin, which in this unfortunate child caused a prolonged illness. I am unable 
to state whether fibrinous pneumonia of children may terminate in a chronic 
condition, apart from the development of a pulmonary abscess, especially that, 
by the formation of new interstitial connective tissue, there is an induration 
of the affected lobe which finally causes bronchiectasis by contraction of the 
newly formed tissue. The cases which have been designated u interstitial 
pneumonia" (Steffen and others) are not sufficiently clear in their develop- 
ment to be definitely regarded as a termination of a u croupous pneumonia " ; 
at least I have not been able to demonstrate this origin in a large number of 
cases of pulmonary contraction in children. The development of this condi- 
tion from a chronic broncho-pneumonia however cannot be doubted. Nor will 
I deny that a pneumonic consolidation under some conditions, not always 
apparent, may require an unusually long time — several weeks, or even months 
— for complete resolution. A case of this kind wherein two months elapsed 
before all of the physical signs of consolidation had disappeared, has been 
recorded by me ; 1 but even here I could not be positive whether small pus 
foci, which could not be demonstrated by physical diagnosis, retarded recov- 
ery. However, certain symptoms (remittent fever, emaciation, occasional 
blood-streaked sputa which later became purulent, but in which threads of tis- 
sue could never be found) seem to justify this suspicion. Although I have 
never observed a case of pure fibrinous consolidation which ran such a chronic 

i " Vorlesungen iiber Kinderkrankheiten," 10 Aufl., 1899, p. 392. 



600 PNEUMONIA OF CHILDREN AND ITS TREATMENT 

course in an otherwise healthy child, nevertheless, it must be noted that chil- 
dren who have once suffered from pneumonia are predisposed to further 
attacks and that even a relapse may follow quickly. A child, aged 4 years, 
suffering from pneumonia of the left lower lobe, was again attacked in the 
same lobe immediately after the defervescence. Again, in a boy of 3 years, I 
saw a pneumonia of the right succeeded by a pneumonia of the left lower lobe 
in the course of fourteen days, with a favorable termination. 

COURSE 

In contrast to the almost continuously tumultuous course of the fibrinous 
form, broncho-pneumonia shows from the onset a decided tendency to protrac- 
tion, wavering between improvement and aggravation. There is frequently a 
transition to a chronic condition which may last for months and lead to the 
development of other serious affections. It cannot be denied that often com- 
plete recovery may ensue after the disease has continued for months; I have 
repeatedly demonstrated this fact clinically and also by anatomical investiga- 
tion in children who succumbed to other diseases soon after their recovery from 
broncho-pneumonia. The possibility of complete resorption of the fatty con- 
tents of the alveoli is therefore evident. But in the course of this disease 
there are so many threatened dangers which originate from the reaction of the 
prolonged limitation of respiration upon the entire infantile organism that the 
prognosis should always be made with the greatest caution. As sequels of this 
condition there may be insufficient oxidation of the blood and stasis of the 
venous system, anemia and general debility, or more or less extensive edema, 
and even dilatation of the right side of the heart. The last change I found 
particularly developed, coincidently with partial fatty degeneration of the 
myocardium, in a few cases of broncho-pneumonia which occurred as a com- 
plication of whooping-cough, probably because the frequent paroxysms .of 
cough increased the resistance which the heart had to overcome from the long- 
continued consolidation of the pulmonary tissue. Under such circumstances 
death may occur unexpectedly as a result of syncope. It must also be remem- 
bered that in such a prolonged febrile disease the appetite is much decreased 
and in infants the ingestion of food is influenced by the dyspnea, which makes 
nursing difficult. When such a child attempts to feed from the breast or a bot- 
tle it will be noted that he lets go of the bottle after a few moments to breathe. 
It may therefore become necessary to feed the child with a spoon or from a cup. 
Even then the food may be rejected, and as a consequence the debilitation al- 
ready present will increase. Here the weakness of the inspiratory muscles plays 
the most important role. The respirations become more rapid (I have counted 
over 100 in a minute), and more superficial. They may at intervals resemble 
the Cheyne- Stokes type, and it is clear that these deficient inspirations may se- 
riously influence the existing atelectasis. The power to cough is lessened and 
this symptom finally disappears — an exceedingly unfavorable sign; for al- 
though children from 8 to 10 years of age rarely eject sputum, they raise it to 



COURSE 601 

the level of the pharynx and swallow it. When cough disappears, this means of 
expulsion is no longer possible, and the widely distributed large and small 
moist rales, and in part the crepitant rales, denote an over-filling of the 
bronchial twigs with mucus. Carbonic acid poisoning finally develops as a 
consequence of this respiratory insufficiency, and these little unfortunates be- 
come somnolent and perish, occasionally during convulsions. In every exten- 
sive broncho-pneumonia the physician must consider these dangers, and he will 
be fortunate to have even a portion of the cases terminate in complete recovery, 
with a gradual cessation of the threatening symptoms. 

The environment of the patient has a great bearing on the prognosis. 
Those who are most endangered, as I have already indicated, are the inmates 
of foundling institutions, hospitals, or those who live in badly-ventilated, 
crowded rooms. Usually there is another deleterious factor, the continuous 
recumbent posture^ which is a further hindrance to respiration, giving rise to 
hypostasis of the lower lobes. Among the well-to-do improper hygienic condi- 
tions are not common, so that the affection does not develop to such a serious 
extent, and recovery occurs more readily. Under favorable hygienic condi- 
tions cases which I considered almost hopeless have terminated in recovery 
notwithstanding many fluctuations. The previous health of the child has an 
important bearing on the course of broncho-pneumonia. Children in whom 
the affection develops from a simple bronchial catarrh are much less endan- 
gered if they were previously healthy than weak, anemic children, especially 
rachitics with a prominent chicken breast. In the latter we are not dealing 
alone with a lessened resistance, but, by the limitation of the cavity of the 
thorax a mechanical factor is added which decidedly increases the danger. 
Also, in these cases, extensive atelectases are particularly frequent, and for this 
reason every bronchitis, and certainly every broncho-pneumonia, is to be- re- 
garded from the onset- as more serious than in a previously.; healthy, -non- 
rachitic child with a normal chest • The same is true, although not always -to 
the same extent, of broncho-pneumonia which occurs in . combination with 
debilitating diseases, especially a prolonged intestinal catarrh, — a condition 
which I have already mentioned as being frequently referred to the entrance 
of intestinal bacteria into the respiratory tract. That tuberculous children are 
greatly endangered by broncho-pneumonia is self-evident, and the condition is 
all the more serious in these children if there is a predisposition to bronchial 
catarrh. 

Among the acute diseases with which broncho-pneumonia may be associ- 
ated — very frequently in a dangerous form in consequence of the accompany- 
ing catarrhal affection — measles must be especially mentioned. In rare instances 
I have seen this complication in the prodromal stage, or simultaneously 
with the development of the exanthem, but, notwithstanding the very 
intense symptoms, the affection is less serious at this period than later, after 
the eruption begins to fade and the fever falls by crisis. If fever again devel- 
ops in the succeeding days we should at once think of broncho-pneumonia, and 
a careful examination of the chest should always be made. This rise in the 



602 .PNEUMONIA OF CHILDREN AND ITS TREATMENT 

temperature may be due to some other condition, as an otitis media, but a 
positive knowledge of the condition of the lungs is imperative. Therefore it is 
absolutely necessary to take the morning and evening temperature even for 
days after the defervescence, so that we may recognize the first symptoms of 
fever and act accordingly. Thermometry is of inestimable value in this condi- 
tion. 

Xext to measles, influenza and whooping-cough must be designated as the 
most frequent causes of broncho-pneumonia. By far the majority of children 
who succumb to these diseases suffer from inflammatory lung affections which 
are not common in the other infections. But even in scarlet fever and en- 
teric fever we cannot be too careful, and in enteric fever in particular the 
lungs must be thoroughly examined, as a general debility may affect the inspir- 
atory muscles to such an extent that the rales heard in the smaller bronchi 
only become distinct upon deep inspiration, which can usually only be pro- 
duced in older and more intelligent children. 

In diphtheria also we must reckon with this complication, whether it runs 
its course with or without implication of the upper respiratory passages. 
Therefore, in diphtheritic croup a serious symptom is a sudden rise of the 
noisy respiration from the normal frequency to 40 or 60 per minute. We may 
then be certain that broncho-pneumonia has developed ; that it is not alone due 
to a propagation of the inflammation from the larynx and trachea, but also to 
the aspiration of diphtheritic products from the upper respiratory passages, as 
was proven by a case in which I found extensive broncho-pneumonia, with par- 
tially septic, decomposed foci, and complete integrity of the larynx and trachea. 
It is, therefore, not justifiable to ascribe the cause of this fatal complication to a 
tracheotomy, as has frequently been done. Tracheotomy alone has very little 
to do with the condition ; it may only prove serious in consequence of " deglu- 
tition " — an accident which is not infrequent — whereby a portion of the in- 
gesta finds its way to the respiratory passages and is aspirated into the 
bronchi; therefore it plays the same role as in other pathologic conditions 
which favor such a process, particularly of the cerebrum. It is, then, the irri- 
tation caused by the particles of food which find their way into the bronchi 
which produces the serious pulmonary condition known as " deglutition pneu- 
monia." 

I have always been under the impression that the broncho-pneumonias 
which occur as a complication of the foregoing infections are much more 
serious than those forms which develop from a simple bronchial catarrh, not 
only on account of the dangers which arise and which are probably increased 
by the infectious nature of the condition, but also from their great tendency 
to an exceedingly protracted course which may continue for months, and — 
what I must emphasize particularly — because of the pathologic picture which 
they present which closely resembles tuberculosis. Tenacious cough, dyspnea, 
sighing expiration, remittent fever with evening exacerbation, and in par- 
ticular the increasing debility and emaciation, which in some of my cases 
was so marked as to be almost skin and bones, readily justify the suspicion 



COURSE 603 

of a caseous decomposition of the broncho-pneumonic infiltrates. In this 
condition the physical signs, the catarrhal and crepitant rales, continue undi- 
minished, while dulness of the percussion note in the areas originally attacked 
may disappear, to become prominent in other portions which were previously 
exempt. This variation, the conditions of which I have already described, 
is even a favorable sign in so far as it shows the resolution of some portion 
of the infiltrate. But there are frequent cases in which this variation does 
not occur; on the contrary, dulness, feeble or indistinct respiratory murmur, 
bronchial respiration and crepitant rales are constantly present in the same 
area. Under these circumstances the diagnosis of " phthisis " forces itself 
upon us, particularly when the seat of this chronic consolidation is not only 
at the lower portion of the lungs, but also in one of the upper lobes. That 
the diagnosis of phthisis may be justified is undoubted; every physician 
knows that tubercle bacilli find a particularly favorable soil in broncho- 
pneumonic areas of consolidation, and a certain percentage of these chronic 
cases succumb from tuberculous caseous decomposition of an infiltrate. The 
diagnosis is all the more uncertain because of the difficulty in obtaining 
sputum for examination for bacilli. Only recently I experienced this trouble 
in a child who was approaching the age of puberty; in spite of all efforts 
some months elapsed before we succeeded in obtaining sufficient expectora- 
tion to demonstrate the presence of the pathogenic microorganism. The 
difficulty is even greater in young children, where we may be able to attain 
our object only by cautious removal of the contents of the pharynx after an 
attack of cough. The search in the feces for bacilli which have been swal- 
lowed appears to me to be a problematic process. Dependent upon such an 
investigation the diagnosis may remain uncertain for some time, and many 
a case may be regarded as hopeless. Fortunately, complete recovery may 
nevertheless occur, and we must, therefore, assume that the threatening symp- 
toms probably do not depend upon a tuberculous degeneration but only upon 
the unusually long existence of the insufficient respiration, and that their 
effect upon the general condition is dependent upon the broncho-pneumonia. 
In the hospital I have seen such children years afterward so robust that I 
would never have recognized them had not their parents brought the pre- 
vious admission card, on which the diagnosis had been noted as an aid to 
my memory. In private practice we may be even more hopeful. I recall the 
child of a landowner in the neighborhood of Berlin, referred to me with a 
diagnosis of " intermittent fever" who at once impressed me as a person 
suffering from pulmonary disease on account of the emaciation, dyspnea, 
cough, and markedly remittent fever. After recovery from broncho-pneu- 
monia some months previously the child retained an extensive consolidation 
of the left upper lobe. The patient recovered after careful nursing and a 
residence for two winters in the south. In cases of this kind are we to 
assume a " cured tuberculosis " after bacilli have been manifest ? And par- 
ticularly after such an advanced stage as might be assumed from the phys- 
ical signs? I believe this to be absolutely unjustifiable. On the other hand 



604 PNEUMONIA OF CHILDREN AND ITS TREATMENT 

it is quite possible that in this consolidation small pulmonary abscesses occur, 
in that the alveoli which are filled with epithelium and new cells rupture 
here and there and form larger cavities by confluence, which, however, escape 
detection on account of their slight extent. As a matter of fact, in chronic 
broncho-pneumonia I have observed abscesses the size of a hazelnut ; for 
example, a child, who remained in the hospital nine days, twice had a tem- 
perature of 38° to 39° C. (100.4° to 102.2° F.) and presented a normal or 
subnormal temperature in the intervals. An abscess formation is particu- 
larly favored in those broncho-pneumonias arising from small foreign bodies 
which find their way into the bronchioles. I have seen two such cases, in 
which, after the symptoms of a broncho-pneumonia had persisted for months 
and a fatal termination seemed unavoidable, a glass bead and a bean respec- 
tively were expectorated with thick pus or pus containing blood. The first 
child recovered; the second escaped my further observation. The preceding 
case, however, shows that even without such a cause, the formation of small 
abscesses is possible, and although I do not maintain that small pus foci are 
-present in all cases which resemble phthisis and terminate in recovery, never- 
theless it must be admitted that in at least a portion of the cases the serious 
prolongation of the illness may thus be explained, especially when hemor- 
rhagic sputum is sometimes present in addition to the above mentioned 
symptoms. I have observed this condition a few times in older children, a 
fact which would still further justify the suspicion of phthisis. Whatever 
our opinion, we must never omit a careful microscopic examination for 
pulmonary tissue if sputum is at all obtainable. 

PROPHYLAXIS AND TREATMENT 

The treatment of infantile pneumonia, which we will now consider, is a 
subject concerning which there is much diversity of opinion. Although, as 
in therapeutics generally, there may be unanimity as to certain fundamental 
principles, nevertheless, individual views, insufficient criticism of our own 
and other experiences, blind confidence in new remedies and their applica- 
tion, play so great a role that it would be a difficult and thankless task for 
me to describe the therap}^ which is largely dependent upon the experience of 
others and is not subject to my own control. I prefer, therefore, to discuss 
only such therapeutic measures as I have found of value in my long hospital 
and private practice, whereof my observations, fortunately, coincide in the 
main with those of the most experienced investigators. 

In primary fibrinous pneumonia the prophylaxis is as little efficient as 
in most of the infectious diseases; nor are preventive measures at our com- 
mand in the epidemics and endemics of pneumonia, which, however, are 
relatively rare in children and fortunately are limited in extent. Inversely, 
in the treatment of broncho-pneumonia, which must be directed to the pre- 
ceding catarrhal condition, prophylactic measures are of avail. This is espe- 
cially true of bronchial catarrh in infancy because then there is a tendency 



PROPHYLAXIS AND TREATMENT 605 

for the catarrh to propagate itself with surprising rapidity to the medium- 
sized bronchi and further downward. Here great care is necessary. The 
belief of many women that, even during storm and rain, fresh air is best 
for their children, is difficult to dispel, and many broncho-pneumonias, par- 
ticularly among the poor, are due to exposure and insufficient clothing. I 
cannot agree with those physicians who advise that children suffering from 
whooping-cough should be kept in the open air even in bad weather and in 
winter, because not only does this method not benefit the child, but the 
catarrh which accompanies the condition may rapidly lead to grave broncho- 
pneumonia. It is important, particularly in the first three years of life, to 
protect children from "taking cold" (sit venia verbo), and they should be 
put to bed as soon as there is even slight fever. By an observance of these 
rules much danger may be averted. 

Treatment of Primary Pneumonia. — We will now turn to the treatment 
of primary fibrinous pneumonia. It has been already stated that in the first 
days of this disease a diagnosis is often impossible and there is then only one 
requirement to fulfil, which is indicated by the high fever. It is a matter 
of course that the sick child must be kept in bed ; the thirst must be relieved 
by cooling drinks (lemonade, orangeade, etc.), while the decreased appetite 
or refusal of food necessitates but small quantities of milk or starchy sub- 
stances (gruel or grits), xlpplications of ice to the head are advisable, par- 
ticularly if there is severe headache with somnolence and delirium. Local 
withdrawal of blood from the head should only be considered when there are 
pseudo-meningitic symptoms, which have previously been detailed. But even 
in these cases I must enjoin caution, because blood-letting is unnecessary. 
As soon as the pneumonic symptoms become prominent (after two or three 
days) the cerebral symptoms grow indistinct or disappear spontaneously; 
therefore a little patience should be exercised. B.ut I must admit frankly, 
from my own experience, that with the appearance of fulminant symptoms 
(convulsions, sopor) there is a great temptation for energetic action, and the 
physician, lest he be neglectful, will apply leeches to the head to avoid a 
possible meningitis. It is true he will not do much injury to a normal child, 
provided after-bleeding is not profuse, but it must be observed that in chil- 
dren an arrest of the bleeding is not always easy and, as a consequence, there 
may be a very undesirable diminution of strength. In any event, it is better 
to limit the treatment to the application of ice and patiently to await the 
further course of the disease. 

Even after the diagnosis has become manifest we can do little more than 
wait. In the treatment of pneumonia there is one fundamental law, namely, 
not to do too much. In children, much more than in adults, the principal 
danger is the appearance of cardiac weakness. Therefore, everything which 
favors this calamity must be avoided, and for this same reason I am seri- 
ously opposed to the repeated employment of internal antipyretics, such as 
antipyrin, phenacetin, and aspirin, because in small doses they are ineffectual, 
and large and repeated doses may produce serious results. Quinin (0.3 to 



606 PNEUMONIA OF CHILDREN AND ITS TREATMENT 

1.0 [5 to 15 grains] given during the afternoon) is much less depressing, 
but in my experience it lowers the temperature for only a few hours, and I 
have finally decided to abandon internal antipyretics and to limit myself to 
hydropathic compresses of the thorax. I am also opposed to the cool or cold 
baths recommended by some authorities, first, because I regard all " ener- 
getic " remedies as unnecessary, and, secondly, on account of their depressing 
influence upon the cardiac power of the child which cannot be estimated 
beforehand — a condition which I have determined in enteric fever of infancy. 
In their stead I apply wet packs to the upper part of the body from the 
axilla to the navel, wrung from water of about the temperature of the room 
— never from cold water — and changed every hour. I have no objection to 
lukewarm baths, although they exert but a transitory influence on the tem- 
perature. In very excitable children, however, they often have a quieting 
effect which cannot be overestimated. In the winter the sick-chamber should 
not be overheated, the temperature never above 15° C. (70° F.), while in 
summer a room well ventilated, and cooled by means of ice-filled vessels is 
preferable. Instead of packs, hourly spongings of the entire body with cold 
water have been suggested and are of service, although I prefer the packs. 1 

Internal treatment generally may be dispensed with, since there is no 
remedy at our command which has an influence upon the pneumococci nor 
upon the infiltrate which fills the alveoli; nor can we prevent the spread of 
the inflammation (pneumonia migrans). I have limited myself to the em- 
ployment of hydrochloric acid (0.5-1.0 to 120.0), because the taste of this 
mixture is unobjectionable, it is readily borne by the stomach, and also for 
the reason that in private practice, even in our " highly civilized " time, we 
can scarcely avoid a bottle of medicine. 

In my experience the majority of cases run a favorable course under this 
simple treatment. Nevertheless, some of the symptoms may require more 
energetic measures. The cough, which in adults frequently requires nar- 
cotics, is rarely so distressing in children as to indicate such remedies. How- 
ever, should the cough be uncontrollable or, as before mentioned, the little 
patient be very excitable on account of hyperesthesia, I do not hesitate to 
administer small doses of morphin (0.001 to 0.002) once or twice daily, 
from which I have seen good results. When older children complain of 
active pleuritic pains on respiration and cough, it is advisable to use from 
6 to 10 dry cups (according to the age of the patient) over the painful area. 
These usually have an excellent effect, and may be repeated as often as their 
use is indicated, since they remove no blood from the body. I have seldom 
had recourse to these measures, nor have I employed general blood-letting 
by venesection, but this remedy, which was formerly so commonly employed 
in pneumonia of adults, has recently been adopted in children and even 
infants in cases which present the symptoms of marked over-filling of the 

il advise a temperature of about 60°, instead of 70°. A window should always be 
open, but direct draught avoided. The good influence of fresh air is undoubted, and a 
much colder temperature is strongly advised by Northrup. — Editor. 



PROPHYLAXIS AND TREATMENT 607 

heart (cyanosis, great dyspnea, small pulse), and particularly when there is 
also a very extensive or even bilateral pneumonia. Literature contains reports 
of a few such fortunate cases. Thus far I have not found it necessary fo 
employ venesection, but from my experience in the treatment of infantile 
broncho-pneumonia, which is soon to be detailed, I believe that even in these 
rare cases the liberal employment of dry cups over the entire anterior or 
posterior surface of the thorax will be sufficient alone, and will not decrease 
the strength of the patient. 

Special consideration must be given to the danger of cardiac asthenia, 
which is to be feared in pneumonia as in all infectious diseases, and here I 
must caution against the employment of depressing remedies. This danger 
may occur in any severe pneumonia, even without such drugs, not only in 
weak children or those who have been previously ill, but also in strong, 
robust children, and particularly near the time of crisis. The longer the 
period of fever the greater is this danger. With the rapid fall of tempera- 
ture to the normal or subnormal there is a tendency to collapse, with a small, 
slow, or, rarely, a very rapid pulse, great weakness, and a sensation of cold 
with or even without profuse sweating. This condition is distressing to those 
about the patient, but is less serious than would appear ; at least T have never 
seen a child perish under such circumstances. On the contrary, I have always 
been able to restore the cardiac power by the employment of good wine (a 
tablespoonful every half hour), strong meat broths, or a mixture of milk 
and brandy. Such stimulants as the subcutaneous injection of ether or 
camphor were seldom indicated in my cases, but they may prove of service 
where there is a prolonged course and marked debility, as in a child aged 
3 years, whose temperature fell to 34.8° C. (94.6° F.) at the crisis. Although 
such a grave collapse, is rare, it is well to forewarn the parents and to relieve 
their anxiety. 

Treatment of Broncho-pneumonia. — As a rule, therefore, the treatment of 
primary pneumonia is expectant; only with the appearance of certain con- 
ditions already detailed, which force themselves into the cyclic course of the 
disease, are more energetic measures justified. Quite different is the condi- 
tion in broncho-pneumonia, which, by its course and prognosis, does not 
permit of a delay in treatment. Although here as in the primary form we 
do not possess remedies effectual in the resolution of the lobular consolida- 
tion, or which will prevent the formation of new foci, nevertheless, we have 
an important object to attain in rendering the bronchi permeable to the in- 
spired air and thus prevent the development of multiple atelectases. 

Emetics and expectorants have been regarded as the most suitable 
remedies for the fulfillment of this condition. Whether the latter are as 
serviceable as is expected of them is uncertain. In mild cases infusion of 
ipecac (0.2-0.5 to 120), or powdered ipecac (0.01) with calomel (0.02-0.03) 
— remedies which have always been advised in the febrile bronchial catarrhs 
of children — may be given every two hours. In well-developed broncho- 
pneumonia I strongly advise repeated small doses of tartar emetic in the 



608 PNEUMONIA OF CHILDREN AND ITS TREATMENT 

first four or five days of the disease, provided the strength of the child is 
good. My experience with this remedy has not justified the fear of many 
physicians, and in small children I have found this drug to be particularly 
valuable under certain conditions. If, however, the child is already debili- 
tated by the disease or is simultaneously suffering from diarrhea, as is fre- 
quently the case, I believe tartar emetic to be contraindicated. For this 
reason the remedy should seldom be used in hospital practice and especially 
in very young patients, but robust children in favorable surroundings derive 
unquestioned benefit from such treatment, particularly when it is instituted 
during the first days of the disease. It is true it is not always easy to 
determine the exact strength of the patient, and here the " professional tact " 
of the physician will play a greater role than theoretic considerations, which 
are often misleading in the individual case. However, it is always in our 
power to discontinue the remedy with the appearance of depression, and for 
this reason the physician should visit the child at least twice daily. I am 
also particularly cautious in the employment of tartar emetic in my practice 
among the poor and in the hospital, because the anxious, ignorant mother 
frequently disregards the careful directions of the doctor and may thus cause 
a dangerous collapse. My method is as follows: Of a solution of tartar 
emetic (0.05-0.1 to 120, according to the age) I first give a teaspoonful 
every hour until it induces vomiting. The drug is then administered every 
two hours. Should vomiting occur after the first teaspoonful the remedy is 
given at intervals of two hours, and if emesis follows each dose, or there is 
diarrhea, the treatment is discontinued. If vomiting does not occur even 
after three hourly doses it is best to continue the treatment with intervals 
of two or three hours in order to avoid a cumulative effect, which may be 
exceedingly difficult to control. I have seen no serious result from this 
treatment, cautiously continued for days, and very often it exerts an unques- 
tionably favorable influence upon the entire course. The vomiting which 
almost always occurs after the first doses and the expulsion of bronchial 
mucus thereby induced, can scarcely explain the success of the treatment; 
on the contrary, there must be some specific action upon the respiratory 
mucosa for which there is not a ready hypothesis. 

In cases which are unsuitable for treatment with tartar emetic, wherein 
at least temporary relief of the over-filled bronchi and free respiration are 
necessary, an emetic of powdered ipecac is advised (1.0-2.0 in 30.0 of dis- 
tilled water, with 15.0 oxymel scillit., a teaspoonful every ten minutes until 
vomiting occurs ) . We must proceed cautiously even with this remedy because 
vomiting may in itself prove exhausting to debilitated children. In fact, in 
the advanced stage of the disease we must be exceedingly careful with all 
emetics, and if there are symptoms of great debility, somnolence, etc., this 
treatment should be avoided. In such cases, and also those in which tartar 
emetic cannot be employed, a decoction of senega or polygala amara (5 to 
100 with liquor amnion, anis 1.5 and syrup, alth. 20, a teaspoonful every 
two hours) are remedies which increase the cough and therefore increase 



PROPHYLAXIS AND TREATMENT 609 

expectoration. To me the most alarming symptom is the disappearance of 
cough, followed by the constant noisy respiration which indicates the dan- 
gerous over-filling of the bronchi with secretion. 

In addition to internal treatment hydropathic packs of the chest are of 
value (as in the treatment of the fibrinous form). I have had such favor- 
able results from this method in broncho-pneumonia that I unhesitatingly 
recommend it above all other remedies. A towel of a size corresponding to 
the circumference of the body is dipped in water of about the temperature 
of the room, wrung out, placed lightly upon the thorax so that no pressure 
is exerted, and wrapped around the entire trunk from the axilla to the 
navel, but leaving the arms free. Over this a layer of cotton is placed and 
a final protective cover of oiled silk or rubber. This pack remains for two 
or three hours and is renewed continuously during the day and also through 
the night. Should sweating appear, water at a temperature of 26° to 27° C. 
(78.8° to 80.6° F.) should be substituted for the cool water. As to the effect 
of this treatment there may be some dispute. In my opinion several factors 
must be considered : first, the stimulation of deeper inspiration by the con- 
tact of the cool pack; second, a gradual stimulation of the skin which is 
evinced by redness, small papules and desquamation of the epidermis ; finally, 
the evaporation of the water which moistens the air around the child. A 
serviceable adjunct to this very beneficial moisture is a spray-apparatus placed 
upon a table near the child's head, or a tea-kettle which is kept steaming 
day and night, or, best of all, the vapor arising from a solution of sodium 
chlorid or sodium carbonate. The physician must never neglect to advise 
those in charge of the suffering child to carry it upon the arm for thirty 
minutes at intervals of two hours, because an unchanged position upon the 
back or even upon the side favors hypostasis and thus still further limits 
the respiratory area. 

Moderate sweating does not prevent the continuance of the foregoing 
treatment, but I advise its immediate abandonment as soon as sweating 
becomes general or copious. Although it is a rare occurrence, nevertheless 
sudden collapse, similar to that previously mentioned, has appeared under 
such circumstances, which I was forced to combat with wine, dry friction 
of the skin, and even with stimulating drugs. In any event the relatives of 
the child must be prepared for this emergency, for in this condition even 
more than in primary pneumonia it is necessary to avoid asthenia, which is 
so serious on account of the decreased inspiratory power and the production 
of venous stasis of the brain and other organs. I have already stated that 
this collapse in broncho-pneumonia, which is due to a decrease of cardiac 
power, may also arise in consequence of the prolonged fever and the insuffi- 
cient respiration, and the first signs of this dangerous condition require ener- 
getic action by the physician. All other considerations are secondary to this 
indication to improve the weakened energy of the heart. 

Among the internal remedies which must be considered I advise, in addi- 
tion to strong wine or cognac, a combination of camphor with benzoic acid 
40 



610 PNEUMONIA OF CHILDREN AND ITS TREATMENT 

(aa 0.05-0.2) and sacch. alb. 1.0 in powders, one to be given every two 
hours, or when their internal administration is difficult, or a rapid effect is 
necessary, subcutaneous injections of camphor are serviceable. Instead of 
the generally recommended oil of camphor I prefer a solution of camphor in 
ether somewhat like the following: camphor 0.6-1.0 with sulphuric ether 
10.0, of which a Pravaz syringeful may be injected according to indications. 
The injections may be given three or four times daily until there is distinct 
improvement. The red infiltrations which are occasionally visible at the 
point of injection never have had any serious effect on my cases even when 
multiple; on the contrary, in ten to twelve days after the formation of a 
yellowish line of demarcation they disappeared, leaving a sharply circum- 
scribed loss of substance which healed rapidly. 

These symptoms of collapse due to cardiac weakness, just described, must 
not be confounded with those which arise from extensive confluent foci which 
greatly limit the respiratory area. I admit that under these circumstances 
there may be a simultaneous implication of the energy of the heart and a 
complicated pathologic picture is thus produced which makes a choice of 
remedies exceedingly difficult. Under these apparently desperate circum- 
stances rapid action is necessary. There is little to be lost and everything 
to be gained, and in fact, in a number of these cases I have succeeded by 
somewhat drastic measures in bringing about a change for the better and final 
recovery. To produce a powerful derivative effect externally, even in very 
small children, I have had as many dry cups applied to the thorax as space 
permitted. This method of derivation I prefer to vesicants and mustard, 
which were formerly so much employed, primarily for the reason that they 
are less effective, and further, because their improper use may produce very 
undesirable sequels. As this procedure .does not cause loss of blood there is 
no essential deteriorating influence upon the strength of the child, therefore 
I do not hesitate to apply a number of dry cups even with an abrupt onset 
of the disease, and believe that thereby a favorable effect has been attained. 
However, with the usually gradual development of the affection this method 
should not be employed. A second measure which has often proved service- 
able in these cases is a warm bath, lasting about five minutes, in water of a 
temperature about 29° C. (84.2° F.), to be followed by a rapid ablution of 
the head and shoulders with water about the temperature of the room. After 
careful drying the child is enveloped in a woolen blanket, placed in bed, and 
given a few teaspoonfuls of wine. The sweating which may soon occur 
should be stopped so soon as it becomes excessive and threatens to debilitate 
the patient. In the hospital this energetic treatment may readily be insti- 
tuted, but I must not conceal that in private practice it frequently meets 
with the resistance of the parents, and because of the uncertainty of success 
the physician himself sometimes hesitates to face the reproach of the rela- 
tives in the event of failure. 

I have attempted, in so far as my experience justifies, to present the 
indications for the treatment of infantile pneumonia, and the conditions 



PROPHYLAXIS AND TREATMENT 611 

suitable for its fulfilment. But I know only too well that these therapeutic 
measures will not always appear sufficient when it is necessary in the indi- 
vidual case to decide in favor of any particular method. As a matter of 
fact, I believe it to be impossible to describe a method which will prevent 
therapeutic variation. Although the cases in general which the physician 
has to combat have much in common, nevertheless there are such essential 
differences that his judgment alone must determine which therapy will be 
the most efficient, and at the same time he must observe the fundamental 
law, that it is not the disease but the individual that is to be treated. Here 
error may readily occur, not alone to the tyro in practice, and, unfortunately, 
cannot be avoided. Only with experience can the physician hope for surety 
in treatment. 

[Very few therapeutic remarks are herewith ventured in connection with this 
clinical masterpiece of the famous teacher, of several generations. Yesicatories 
should be avoided, for they rob the patient of rest and sleep. The treatment 
with tartar emetic is risky. It may prove depressing, and cause diarrhea. It is 
the treatment of (Teschier and) Rasori, the remodeler of Brownism. Eighty 
and sixty years ago it was quite popular in Europe, and in my clinical work 
nearly 60 years ago, and during my first decade in New York fifty years ago 
I employed it much. Afterward I substituted for it the oxysulphuret of 
antimony but gave it up on account of the occasional depression caused by 
the antimony even in that mild form. Whatever weakens should be avoided. 
Every day of a pneumonia, both fibrinous and broncho-pneumonia, adds to 
the debility of the patient and of his heart. Mild or full stimulation should 
not be postponed until " the necessity turns up," that means often until it 
is too late. From that point of view the master recommends alcohol at an 
early date. My personal experience speaks against it in the first few days, 
but small doses of digitalis or spartein are well tolerated. The 1 drop dose 
of liq. amnion, anisatus is too small for any effect. Four or six drops are 
a dose for the smallest child. The carbonate of ammonia may upset the 
stomach. Benzoic acid has that effect too often, it has a very bad taste and 
should be avoided. Camphor is too little employed by us. Camphor water, 
or camphor in diluted mucilage is easily tolerated, and acts beautifully as 
a stimulant and expectorant. Its solution in ether as a subcutaneous injec- 
tion is reprehensible on account of intense pain ; the camphor oil of the Phar- 
macopoeia is too thick. The best solution is in sweet almond oil 1 : 4. — 
Editor. 1 



ROTHELN, RUBELLA, GERMAN MEASLES 

By Ch. Baumler, Freiburg 

The conditions of hospitals in which eruptive infectious diseases are 
treated, as a rule, are such that the student only sees in adults those diseases 
whicli, later on in life, he encounters principally among children. This also 
has its advantages. On the one hand, many peculiarities are noted regarding 
the appearance and course of eruptive diseases which occur particularly in 
infancy, such as measles, scarlatina and rubella, which are then of value in 
judging the condition in children. On the other hand, the study of the previ- 
ously mentioned diseases in adults is important in a differentio-diagnostic re- 
spect, as in them conditions arise in which the decision in the individual case 
is of far greater importance than in the case of children. 

The following history of rotheln will serve as a text for the description 
of the disease : 

H. J., locksmith, aged twenty-one, was admitted to the hospital May 18, 1900. He 
had previously been well, and the day prior to admission, without any other symptoms, 
with the exception of a mild coryza, noted red spots upon his arms and chest. 

Upon admission he had an axillary temperature of 100° F., pulse 100 per minute, 
and upon the entire face, upon the neck, trunk, and upon the arms, as well as upon 
the thighs, a light red macular eruption was present. The face showed no diffuse red- 
dening and on the rest of the body the skin was pale between the indented, here and 
there confluent, spots. At many points in the eruption, the somewhat swollen cutaneous 
follicles were reddened. The eyelids were swollen, the conjunctiva moderately injected, 
the upper and lower lips were covered with spots, and the pharyngeal mucous mem- 
brane was somewhat reddened; there was no decided swelling. 

Bilateral enlargement of the superficial cervical glands. 

Nothing abnormal in the organs of the chest, no catarrhal phenomena. 

Splenic dulness extended 6 cm., border of spleen could be felt. 

Urine free from albumin, no diazo-reaction. 

Temperature, eight o'clock in the evening, 99.7° F. 

May 19th: The eruption had almost the same appearance as the day previously. 
The record states: 

Upon the lower legs some few individual spots are noted, the palms and dorsum of 
the hands are free from eruption, the cervical glands have become somewhat larger, and 
the inguinal glands appear more or less swollen. The temperature in the morning 
is 98.6° F., pulse 88, respirations 22. 

Evening temperature 98.9° F. 

May 20th: Normal temperature and normal pulse (98.4° to 99.2° F., pulse 75), 
eruption becomes paler and has spread to the lower leg, also upon the dorsum of the 
foot, in the latter region consisting of small, irregular, partly net-like, arrangement 
of macules. 

May 21st: The clinical history shows that the mucous membrane of the pharynx is 

612 



ROTHELN, RUBELLA, GERMAN MEASLES 613 

still slightly reddened and that the patient complains slightly of pain in deglutition. 
In the evening a temperature rise to 100.8° F. In the face distinct, small-scaled 
desquamation. 

May 23d: As the remainder of the eruption, only a delicate marbling of the skin 
is seen, but the pharyngeal mucous membrane is still red, however, without swelling. 
The cervical lymphatic glands upon the left side are still markedly enlarged, those 
upon the right to a less extent. Splenic dulness amounts to 5X7 cm. The patient 
feels perfectly well, has a good appetite, sleeps well and leaves the clinic on May 26th. 

This eruptive disease has then shown itself to be an exceedingly mild 
almost afebrile affection. If the eruption, which was noted by the patient, had 
not appeared he probably would not have come to the hospital. 

Among the clinical symptoms, apart from the description of the eruption, 
I shall especially mention two which are of some importance in rotheln. 
These are: First, the enlargement of the superficial cervical lymphatics behind 
the sternocleido mastoid; and, second, the enlargement of the spleen. 

Regarding the lymph glands, in our case the inguinal glands w r ere also 
found somewhat enlarged. Very probably this glandular enlargement is less 
common, but those mentioned belong to areas of the body in which enlarge- 
ment of the lymph glands may be most readily determined. In many cases 
this may also be noted in the axillary and cubital regions, or even in the small 
glands under the skin, upon the lateral aspect of the thorax. 

This lymph-gland enlargement, which is never very considerable, but still 
quite plain, has a certain differentio-diagnostic importance according to the 
investigations made in this clinic. 

In measles a lymphatic enlargement does not occur so early, although an enlargement 
of the lymph glands occurs after the development of the other symptoms, above all, 
depending upon the severity of the catarrhal phenomena of the upper air-passages. In 
scarlatina it is not primarily the superficially situated lymph glands, those situated 
behind the sternocleido mastoid, but those at the angle of the lower jaw and situated 
in front of the last-named muscle which, in connection with the severe inflammatory 
condition of the throat, enlarge early and are often even sensitive to pressure. 

From this early, usually not considerable, enlargement of the lymph glands, there 
is to be distinguished a condition that occurs frequently in scarlatina, more rarely in 
measles, and perhaps also, occasionally, in rotheln, a subsequent inflammatory swelling 
which often terminates in abscess formation. In scarlatina the condition not infre- 
quently shows itself in the third and even in the fourth week after the onset of the 
disease, after the fever which is in connection with the process has run its course, 
developing a fresh febrile curve and occasionally arising simultaneously with the phe- 
nomena of scarlatinal nephritis. 

The lymphatic enlargement in rotheln, according to the observations which 
Clement Dukes made in a school, may be the first symptom of the disease, 
appearing before the cutaneous eruption. 

The enlargement of the spleen is but very moderate, but, nevertheless, it 
is present from the onset of the affection up to the time of convalescence, and, 
if the contour of the spleen is drawn upon the skin and measured, it cannot 
be missed. The enlargement is somewhat less than in the case of scarlatina 
but more marked than in the case of measles in which the enlargement of 
the spleen, according to our observations, does not go beyond its usual borders. 



614 ROTHELN, RUBELLA, GERMAN MEASLES 

Diagnostically, tliis may be of importance in doubtful cases as in all acute 
eruptive diseases the consideration of all the accompanying phenomena, as 
well as of the eruption, is of the greatest importance. The diagnosis in an 
acute eruptive disease, especially in childhood, may, under some circumstances, 
be exceedingly difficult and is often combined with great responsibility on the 
part of the physician. 

Compared with measles, and especially with scarlatina, rotheln is a disease 
of but very slight importance. According to the very careful investigations 
of Thomas, Emminghaus, and others, the disease runs its course entirely 
without fever, in some cases fever, with a temperature of 102.2° F. It is 
highest at the onset of the disease and falls by rapid lysis. Therefore, in the 
case of rotheln the fever is not in close connection with the eruption, as is 
the case in measles, in which the maximum of the acme of the fever is in 
proportion to the height of the eruption, and, then, if no complications occur 
to cause a deviation from its usual course, falls by crisis. 

In rarer cases of rubella, besides a marked rise in temperature, there may 
be symptoms which are common to other febrile diseases, being in part de- 
pendent upon the individuality of the patient, such as general lassitude, head- 
ache and restlessness. Herpes labialis has also been occasionally observed. 

Some sequelce, such as eczema, herpes zoster, marked angina tonsillaris, 
purulent inflammation of the lymph glands, erysipelas, albuminuria, which 
have here and there been observed, are in no direct connection with the specific 
rubella infection, which, for the most part, is only the impetus for other 
infections to appear. These sequela?, however, are very exceptional. It is 
the rule that rotheln is a quite harmless affection, running its course, in many 
cases, without serious consequences. Therefore, when the diagnosis can be 
made with certainty from the first appearance of the eruption, although we 
are dealing with a contagious disease, to which the susceptibility in infancy 
is a very great one, isolation of the patient is not necessary. On the other 
hand, in a mild case of scarlet fever, in which we are never quite certain 
whether serious complications may arise or not, and from which, by trans- 
mitting contagion to another, the severest, absolutely fatal form of scarlatina 
may arise, isolation is imperative. In measles, at least as regards sickly or 
weak individuals in the cold seasons of the year, in which severe complications 
are likely, especially on the part of the lungs, isolation is advisable. There 
are, however, especially in scarlatina, mild forms with but feebly characterized, 
or but sparse and locally limited eruptions and slight throat phenomena. On 
account of the mildness of the affection, and perhaps also on account of the 
variety of the eruption, the danger of diagnosticating rotheln in such a case 
is especially great if, at the same time, rotheln is epidemic, but, as is common 
in large cities, sporadic cases of scarlatina occur from time to time even with- 
out an epidemic. Suppose such a case occurs in a child belonging to a family 
in which there are many children, or happens in a house in which there are 
many families with numerous children, or in a large boarding school; rotheln 
is diagnosticated, the case is looked upon as mild and without serious conse- 



ERUPTION 615 

quences, isolation is not regarded as necessary, and after the child appears to 
have recovered he is permitted to return to school. After a few days a brother 
or a schoolmate is attacked by typical scarlatina and perhaps succumbs rapidly 
to the severity of the affection or perhaps another child that also came in 
contact with an apparent rubella patient is affected by mild scarlatina, in the 
course of which, however, otitis media occurs with a permanent injury to the 
ear, or an endocarditis develops which gives rise to chronic valvular disease, 
or a severe renal inflammation, with uremic phenomena and dropsy appears, 
from which permanent changes in the kidney remain. Apart from the mis- 
fortune to the affected family, what consequences an occurrence of this kind 
will have for the reputation of the physician need not be enlarged upon. And 
all this might have been prevented if, by precaution, a positive diagnosis had 
not been made in the first place, but the patient had been isolated and the 
further course of the affection observed. What has been said is sufficient to call 
attention to the responsibility of the physician in cases of this kind. 

From this it may be seen that in the diagnosis of eruptive diseases, espe- 
cially in infancy, it is the duty of the physician to be exceedingly careful to 
take into consideration all factors and rather err on the side of too much 
care than, without certain signs of support, to make a positive diagnosis which 
subsequently proves to be erroneous. Every case that is at all doubtful is to 
be isolated if there is danger of the presence of a serious disease such as scar- 
latina or measles or variola, for these must all be taken into consideration in 
the first stages of the eruption. 

Eruption. — The eruption in rotheln must be carefully considered as this 
is the symptom which impresses the stamp upon the affection, and it is the 
exanthem which is the most important differentio-diagnostic point in the 
eruptive diseases in general. Before describing the eruption of rotheln, I must 
state a fact which should be remembered in every case. It is this, that a 
cutaneous eruption, perhaps due to a specific cause of an infectious nature, 
is not alone dependent upon this cause for its appearance, but also upon the 
structure and condition of the skin of the affected individual, therefore, it is 
dependent also upon age, general nutritive conditions, circulatory circum- 
stances, the manner of reaction of the nervous system and upon cleanliness. 
Eegarding the skin, it is a well-known fact that in persons of the same age, 
one may have a fine, and the other a coarse skin ; in the former the cutaneous 
glands are scarcely visible, whereas in the latter they are quite prominent; 
in one the epidermis is so tender that the capillary net may present itself as 
a reddish surface, whereas in the other redness is scarcely noted, even in the 
majority of light complexioned individuals, in parts that are usually promi- 
nently red, such as the cheeks, although such individuals may be in the main 
entirely healthy and by no means anemic. 

According to the condition of the skin, the same cause which produces 
an eruption which primarily causes a macular dilatation of the superficial 
capillaries of the skin, in which, especially the capillary circle, the mouths of 
which surround the cutaneous follicles, is more markedly filled with blood will 



616 ROTHELN, RUBELLA, GERMAN MEASLES 

produce quite a varying picture in different persons. I take it for granted 
that the skin is well cared for and that the appearance and composition of the 
eruption is not partially concealed by dirt or by disturbances in the circulation 
and by general asthenic conditions of the organism. 

In fact, it must be further noted in regard to the eruptive diseases in 
question, that the manner and way in which the causative agents act upon the 
skin are varying and that the variation is influenced by the severity of the 
affection and, above all, by the virulence of the causative agent of the disease. 

Therefore, there may be several circumstances which, in the individual 
case, may prevent an eruption from appearing in a typical manner, so that 
it will be well nigh impossible to formulate a diagnosis, except by means of 
the other conditions : proof of contagion from a well characterized case, the 
existence of an epidemic, symptoms and prodromal phenomena of a distinct 
and characteristic kind. 

It must be mentioned, above all, that there is no typical uniform eruption 
in rotheln. Of the three acute eruptive diseases that have been mentioned, 
the eruption in rotheln varies the most 

Whereas in the case of measles there are indented macules, often with a 
small papular formation due to the follicles of the skin, which stand out promi- 
nently with a more or less well defined bluish color, the intensity depending 
principally upon the severity and distribution of the accompanying catarrh of 
the respiratory organs, the cyanosis being due to this, the scarlatinal eruption 
consists of very minute closely intermingled pin-point marks which are found 
upon the uniformly injected, reddish, discolored skin. 

The diffuse reddening is due to a very uniform dilatation of the entire cutaneous 
capillary net, which, however, is by no means due to a paralysis of the vasomotors. 
On the contrary, the smallest cutaneous arteries even show an abnormally increased 
irritability in a similar, but more marked, manner than that which occurs in every 
febrile reddening of the skin in the most varied febrile diseases, and, next to scarlatina, 
is most notable in the case of enteric fever. If we run the finger nail or the end of 
the percussion hammer very gently over the skin there appears very rapidly in a few 
seconds after the disappearance of the pallor due to the pressure, a broad line 1 to 2 
millimetres greater in extent than that produced by the nail or other instrument upon 
the irritated area ; thus designs and words may be drawn upon the skin, these only 
disappearing in from two to three minutes by a slow redilatation of the previously 
narrowed vessels. 

This sort of an erythema of the skin, naturally, can only occur in rotheln 
when the disease runs its course with fever as this is a condition which is seen 
preeminently in febrile vascular dilatation. In measles this occurs particu- 
larly in the stage of the initial fever, before the appearance of the character- 
istic eruption. In this diffuse vascular dilatation, the underlying cause is 
apparently a peculiar action of the pathogenic agent of the disease or the effect 
of certain toxins produced by it upon the vasomotor apparatus. 

The rotheln eruption consists of, at times larger, at other times, smaller, 
slightly elevated papulo-macules, similar to those of measles but lighter in 
color, not bluish but of a rose-red color. In some cases these may be very 



ERUPTION 617 

small so that the eruption at first sight resembles scarlatina more than it 
does measles. Such fine punctiform areas as occur in scarlatina we never see 
in rotheln. But during the fading of the eruption a phenomenon may appear 
which is seen in scarlatina and not infrequently in measles, namely very 
minute punctiform hemorrhages which are situated close together; these are 
particularly noted in the delicate skin of the axillary region below the external 
half of the clavicles. They are of no importance in so far as no other severe 
symptoms are present which point to a hemorrhagic diathesis or to sepsis. 
The individual macules of which the rotheln eruption consists, for the most 
part have an irregular serrated limitation in some cases, and in some areas 
of the body are so far apart that the entire quite normal appearance of the 
skin which lies between them may be determined with certainty. The macules 
give the impression of being slightly raised, but they are not as coarse, as a 
rule, as those which occur in measles. 

Upon the covered parts of the body and at those places at which sweating 
is apt to occur, sudamina appear, similar to the case in other eruptive diseases. 

The distribution of the eruption occurs from the head and face downward. 
It may, however, especially in cases in which the eruption is but slight, 
appear first upon the chest and arms, very frequently, even profusely, upon 
the face, neck, trunk and arms; the eruption is less copious below the knee, 
and on the lower leg and on the feet but few individual macula can be deter- 
mined. 

Eegarding the appearance of the eruption, great variations may occur. 
One point, however, requires exact observation because it is of great diagnostic 
importance : In rotheln, as also in measles, the region about the mouth (upper 
and lower lips, point of the nose) is often profusely covered by the eruption, 
whereas in scarlatina this region of the face is quite conspicuously free from 
eruption and often remains free from any erythema so that it is conspicuous by 
its pallor in contrast to the redness of the rest of the face. 

Another point, which in a diagnostic respect deserves observation and 
which I intend to emphasize again, is this, that in the great majority of cases 
the eruption in rubella is the very first symptom of the disease, whereas in 
the case of measles the eruption appears only upon the fourth day, and in 
scarlatina upon the second day after symptoms have appeared. In the case 
of measles these prodromal symptoms are: fever with coryza and lachryma- 
tion, and, according to the height of fever, more or less well developed general 
malaise, which upon the second and third day, with a decline in the fever, may 
increase. In scarlatina: very frequently at the onset of the affection, vomit- 
ing, fever and pain upon deglutition, with the signs of an " angina f aucium " ; 
with very intense reddening and a quite unusual increase in the pulse rate, 
even out of proportion to the high temperature. 

Desquamation in a profuse rotheln eruption occurs in the form of small 
flakes, especially upon the face, neck and chest ; it is, however, commonly over- 
looked if special attention is not paid to it. 

If fever is present, the urine may transitorily show traces of albumin. 



618 ROTHELN, RUBELLA, GERMAN MEASLES 

Several times in our hospital, in eases of rotheln, we have found the diazo- 
reaction. 

Convalescence in this very mild affection is exceedingly rapid. Remarkable 
is the reappearance of the eruption after the complete disappearance of the 
first attack. But these very rare relapses of the disease, as Emminghaus has 
observed, even with a very rapid course, have their analogy in the relapses of 
other infectious diseases. Accurate descriptions will be found in the exhaus- 
tive monograph on rotheln by Johannes Seitz x in Zurich. 

That in the case of rotheln we are dealing with a substantive, specific 
affection, sharply defined from measles and scarlatina, is now generally 
accepted. The reasons for the separation of both previously mentioned dis- 
eases, besides those already enumerated in the description of the symptoms, are 
these : 

1. That rotheln, measles and scarlatina may follow or precede one an- 
other in the same individual, that, therefore, neither is a protection from 
rotheln, nor the latter a protection from either of the other affections, whereas 
a second attack may occur in measles, as also in scarlatina, but is, however, 
quite rare ; 

2. That the period of incubation is a different one from that in the case 
of the two other affections, in case of rotheln it is about three weeks, seven- 
teen to twenty-one days, in measles only about nine days, and in scarlatina, 
under some circumstances, only one day, but may also be much longer. The 
contagious principle of scarlet fever is extraordinarily resistant so that by 
adhering to clothes and all possible substances (fomites) the transmission is 
often an indirect one. Between the adherence of the contagious principle to 
clothes, etc., and its entrance into the body which is still dependent upon all 
possible eventualities, a varying period of time elapses. 

The great variations which the eruption of rotheln shows in different 
cases, so that it resembles measles, at another time scarlatina, are conditions 
which increase the difficulties of diagnosis provided the other symptoms and 
other circumstances are not sufficient to form an opinion. But a new diagnostic 
difficulty must yet be mentioned. 

The Fourth Disease. — A few years ago, while physician to the great boys' 
school at'Kugby in England, thus having an unusually large field of observa- 
tion for these diseases, Clement Dukes observed that in children that have 
gone through an attack of rotheln an eruptive disease may appear in which 
the eruption more closely resembles scarlatina, the other symptoms, however, 
being against the assumption of scarlatina. If we are dealing with relapses 
from rotheln it is conspicuous that in the second attack the eruption is quite 
different from that of the first attack. Dukes suggests that there is possibly 
still a fourth disease which has something in common with scarlatina and 
with rotheln, but which is neither one nor the other affection. Other physi- 
cians also, principally American and English observers, have, in the course 

i Vorrespondengblatt fiir Schweizer Aerzte, Jalirg. xx, 1890. 



THE FOURTH DISEASE 619 

of the lasi seven years, published observations which are calculated to confirm 
the assumption of a fourth disease (" fourth disease " as Clement Dukes x has 
named the affection). According to Weaver,- the symptoms are, an erup- 
tion resembling scarlatina but which also occurs around the mouth, very 
slight fever, no increase in the pulse rate, no vomiting, no, or but very slight, 
throat phenomena, no desquamation as in the case of scarlatina, and an 
absence of the lymphatic gland enlargement of rotheln. F. T. Simpson 3 noted 
the affection several times after scarlatina, in numbers of instances after 
measles. He observed in several patients of this kind lamellar desquamation. 

Diagnosis. — In children, with their much more susceptible skin and irri- 
table nervous system as compared with adults, there occur, under the influence 
of the most varied causes, more or less well developed eruptions which, at least 
in their primary stages, may cause confusion with one or the other of the spe- 
cific eruptive diseases. Especially in small children, during the period of den- 
tition and in seasons in which intestinal catarrh is frequent, with or without 
febrile phenomena, acute eruptions of brief duration occur, which have been 
called " roseola aestiva " and which may resemble rotheln. In such cases 
rotheln can only be diagnosticated if, at the same time a rotheln epidemic is 
present, contagion can be proven, or if from a patient of this sort contagion 
is spread and an affection resembling rubella appears. In such cases lym- 
phatic enlargement and enlargement of the spleen must be present. Many 
affections of this kind belong to urticaria or also to erythema multiforme, 
which latter affection may also run its course with lymphatic enlargement and 
enlargement of the spleen. 

Etiologically. intoxication or autointoxication plays a prominent role in 
these cutaneous eruptions : in erythema multiforme, probably an infection is 
the cause. It is sufficient to mention the urticaria produced by the eating of 
strawberries, by the ingestion of certain kinds of sea-food, that form produced 
by intestinal worms and by digestive disturbances of various kinds, which, in 
some persons, especially in early youth, is likely to produce this form of 
eruption. As great as is the difference between a macule of rotheln and of 
even a small patch of urticaria, it must not be forgotten that, especially in 
children, any eruption, by friction of the clothes or of the bed and above all, 
by scratching, the irritated areas may develop papules, even wheals. It must 
be further remembered that a purely local irritation of the skin, in individuals 
that are especially susceptible, may cause a distribution over larger areas of the 
skin, by means of scratching; these primarily local irritations being caused by 
the bites of insects, by the hairs of certain caterpillars, by ethereal, oleaginous 
and other vegetable products (thuja — and pinus varieties, primulacea). 

Many drugs may. in some individuals, children as well as adults, give rise 
to eruptions which may distribute themselves over the entire body. On account 
of its great similarity to measles, the first to be mentioned is the eruption 

i Lancet. July 14, 1900. 

2 Dublin.. Journal of Med. Science, 1901. VI. Ref. Fortschritte der Med., 1901, Nr. 35. 

3 Archives of Pediatrics. Sept.. 1901. Ref. in Am. Joum. of Med. Sci., Jan., 1902. 



620 ROTHELN, RUBELLA, GERMAN MEASLES 

caused by antipyrin, which, in children that have had antipyrin administered to 
them on account of whooping cough, is not so infrequently observed. In com- 
parison to the eruption of rotheln, the latter is of a darker color and of a more 
papular character. 

The eruption appearing after the injection of diphtheria antitoxin serum 
may consist of flat macules or papules, and, if at the same time an epidemic 
of rotheln is present, may give rise to confusion. This eruption, as a rule, 
shows larger macules than occur in rotheln, usually irregularly distributed over 
the body and, therefore, more closely resembles erythema multiforme. 

In some persons there is a remarkable idiosyncrasy to quinin, in others to 
mercury, upon internal and external administration. In such persons even 
minimum doses are sufficient to cause a dermatitis which distributes itself 
over the entire body, in which only at the onset the erythema is small, macular, 
soon becoming uniform so that the eruption of scarlatina is closely simulated. 
This diffuse dermatitis, running its course with fever, is accompanied by a 
desquamation of the entire epidermis, large flakes coming away, and occasion- 
ally, also, by a falling out of the hair and the nails. 

In adults, occasionally, the internal administration of cubebs or balsam 
copaiba is the cause of a small papular eruption which may resemble measles or 
urticaria. 

In some regions in which typhus fever is endemic, or where it is brought 
in, measles may be thought of on account of a very profuse eruption, a dif- 
fusely livid discoloration of the skin and the papular consistence of individual 
florescences. These papules, however, are only a small constituent of the erup- 
tion, which, in the main, consists of entirely flat, irregularly constituted, livid 
areas, frequently intermingled with petechia — hence the name petechial typhus. 
The entire course of the disease, in which the eruption appears only upon the 
fourth day, the high fever, the marked enlargement of the spleen, the occur- 
rence of typhus fever in the affected region, and the probability that con- 
tagion has taken place, enable us, with some slight care, even when measles 
and rotheln are simultaneously epidemic, to avoid an error, which, on account 
of the greater transmissibility of typhus fever, might give rise to serious conse- 
quences. 

In epidemic cerebrospinal meningitis, in some few cases eruptions occur 
which show a certain similarity to measles or rotheln, as a rule, however, they 
are more localized to the extremities, a part of the trunk, and more closely 
resemble erythema multiforme than the previously mentioned eruptive dis- 
eases. The presence of an epidemic and of undoubted cerebrospinal inflam- 
matory phenomena is determining above all in the differential diagnosis. 

In an adult, during the prevalence of an epidemic of rotheln, a very profuse 
eruption of roseola syphilitica may appear during the eruptive period of this 
disease, possibly at the same time with the febrile phenomena, so that the 
true nature of the disease is concealed and rotheln is thought of. In both, 
enlargement of the lymphatics and of the spleen is present, in both ' there 
may be a somewhat more decided erythematous condition of the palate with 



DIAGNOSIS 621 

slight swelling. But in an eruption appearing so acutely, especially with 
fever, there is a much more decided general malaise, and, above all, as a rule, 
severe headache which increases toward night, and the greater gravity of the 
disease is already noted in the facial expression. Even to the inexperienced, 
the continuance of the eruption beyond three . to four, days, its increase, not 
from above downward, but a closer approximation, and an increased develop- 
ment of macules into papules will soon show the true nature of the affection. 
The examination of all palpable lymph-gland areas will then show at some 
place in the body a few that are more markedly enlarged, being painless round 
glands ("indolent buboes"), and, in the peripheral area of the same, the pri- 
mary legion may be discovered. 

Finally, in septic affections, eruptions which develop rapidly, being of a 
macular or papular character, not infrequently resembling urticaria, occa- 
sionally being hemorrhagic or postulous, have, at certain stages, some simi- 
larity to rotheln or even measles. By an observation of the accompanying phe- 
nomena errors may easily be avoided. 

It will, therefore, be seen that in the individual case many possibilities 
must be thought of before an opinion is given in an acute eruptive disease. 
Above all, every eruption should be accurately examined, and whenever pos- 
sible, by daylight, and the most recent efflorescences should be sought in order 
to determine their original form, and the further development of the eruption 
should be compared with these. The opinion should never be made to depend 
upon the appearance of the eruption alone, and especially not in those cases 
in which the affection appears to deviate from the ordinary type of the dis- 
ease. Above all, the prodromal phenomena of the disease should be inquired 
into, those that were present before the appearance of the eruption. A com- 
plete absence of these, as has already been noted, occurs especially in rotheln, 
whereas in measles a prodromal stage lasting three days, and in scarlatina, 
one to two days, is present, accompanied with fever, in measles with catarrh, 
primarily of the upper respiratory passages, in scarlatina with angina fau- 
cium, vomiting and an unusual increase in the pulse rate. But very rarely is 
there a constitutional disturbance or sore throat, or coryza in rotheln. In 
measles, before the appearance of the eruption, an alteration of the mucous 
membrane of the cheeks occurs, which is not observed in the case of scarla- 
tina and rotheln and for this reason is of great diagnostic importance. These 
are the so-called Koplik's spots: isolated red points the size of the head of a 
pin with a bluish- white or whitish-yellow point in the centre. In every case 
in which measles is suspected these should be searched for. After the appear- 
ance of the eruption they become indistinct or disappear completely, probably 
under the influence of a more marked hyperemia of the mucous membrane. 

Then the other organs (lungs, heart), above all, the spleen and lymph- 
glands are to be examined; in an examination of the urine the diazo-reaction 
should not be forgotten. 

A careful investigation of the accompanying circumstances, the possibility 
of contagion within the period which corresponds to the incubation period of 



622 



ROTHELN, RUBELLA, GERMAN MEASLES 



the disease should never be neglected, especially in cases in which there has 
been no previous appearance of the disease in the family to clear the situation. 

In every doubtful case a positive diagnosis should not be made, but care 
should be taken that the disease is not transmitted to others, the patient 
should be isolated and the diagnostic decision should be deferred for the next 
few days, until the disease has developed fully. As regards the treatment 
of the patient, nothing will be neglected by this. In those cases in which 
special symptoms are prominent they must be treated on general principle-. 
High fever and cerebral symptoms in scarlatina and measles may require cold 
baths, in rotheln symptoms which require treatment almost never occur. In a 
case of rotheln, therefore, general dietetic hygienic rules are to be followed 
which are self-evident in any mild affection. 

Differential Diagnosis. — A table is appended which shows the character- 
istic differences of the three diseases at a glance : 





Rotheln 


Measles 


Scarlatina 


I. Incubation 


17-21 days. 


9-11 days. 


1-7 days and longer. 


PERIOD. 








II. Prodromal 


None. 


Fever, catarrh of the 


Vomiting, sore throat, 


SYMPTOMS BE- 




upper respiratory 


fever, increased ra- 


FORE THE AP- 




passages and the 


pidity of the pulse. 


PEARANCE OF 




conjunctiva. 




THE ERUPTION. 








III. Eruption: 


First day. 


Fourth day. 


Second day. 


First appear- 








ance. 








Distribution. 


First in the face. 


The same. 


First upon the neck 
and upper parts of 
the chest, the face, 




Upper and lower lips 


also covered with the 


the region about the 




eruj 


)tion. 


mouth remaining 
free. 


Character of the 


Macular or puncti- 


Macular, slightly 


Finest punctiform 


eruption. 


form, color light- 


raised, prominence 


areas, close togeth- 




red. 


of the cutaneous 


er upon a uniform- 






follicles, color blu- 


ly reddened skin. 






ish red. 


Color deep red. 


Desquamation. 


Ill-defined, small 


Small flakes. 


Upon the neck and 




flakes. 




trunk small flakes, 
upon the hands and 
feet, often only 
after weeks, in the 
form of large scales 
(lamellous) . 


IV. Accompany- 








ing SYMPTOMS : 








Throat. 


Catarrhal reddening. 


At the onset, macular 


Uniform marked in- 


- 




reddening then uni- 


flammation with 






form (upon the mu- 


more or less swell- 






cous membrane of 


ing, occasionally fol- 






the throat, Kop- 


licular plugs or 






lik's spots). 


membranous depos- 
its.' Complicated by 














diphtheria. 



DIFFERENTIAL DIAGNOSIS 



623 





R6THELN 


Measles 


Scarlatina 


IV. Continued 








Respiratory 


Sometimes catarrh. 


Marked catarrh, lar- 




organs. 




yngitis, bronchitis 
and bronchiolitis. 
Great tendency to 
broncho-pneumonia. 




Spleen. 


Some enlargement. 


No enlargement. 


Enlargement. 


Lymphatics. 


Superficial cervical, 


Not so constantly en- 


Glands, especially at 




auricular, often also 


larged as in ro- 


the angle of the 




other glands, soft 


theln. 


lower jaw enlarged; 




and frequently sen- 




cervical glands 




sitive to the touch. 




later on, as a com- 
plication often with 
abscess formation. 


V. Fever. 


Often no fever, or but 


Prodromal fever last- 


Highest temperature 




slight rises in tem- 


ing three days. 


at the onset. 




perature, rarely to 


Temperature rises 






102° F. Highest 


with appearance of 






temperature usual- 


eruption, maximum 






ly upon the first 
day. 


of both at the same 






time. 




Defervescence. 


Lysis. 


Crisis. 


Lysis. 


VI. Complica- 


No constant nor fre- 


Broncho - pneumonia, 


Endocarditis. Acute 


tions AND SE- 


quent ones. 1 


otitis media. Tu- 


rheumatism. Ne- 


QUELS. 




berculosis of bron- 


phritis. Otitis me- 






chial glands and 


dia. Septicopyemia. 






lungs. General mil- 








iary tuberculosis. 








Noma. Diphtheria. 








Rarely nephritis. 





i The complications and sequelae mentioned under measles and scarlatina are not 
" constant." On the other hand, the presence of nephritis does not exclude the diagnosis 
of " Rotheln." It will occasionally occur as a sequela. — Editor. 



MEASLES, MORB1LLI, RUBEOLA 

By O. Heubner, Berlin 

Definition. — By the designation measles, we understand a febrile disease 
of the upper respiratory mucous membranes and of the general cutaneous 
coverings, having quite a typical course in its symptoms, belonging to the acute 
exanthemata, and which is always due to the entrance of a specific poison 
derived from a previous case of measles. 

Etiology. — Although in the descriptions of authors of the middle ages 
measles cannot be recognized with certainty, it is at least likely that we are 
dealing with a very ancient disease, perhaps of the same age as variola. The 
susceptibility of the human race to the poison of measles, in spite of repeated 
infection, has not been attenuated even to-day, for but very few persons, com- 
paratively, fail to have an attack of measles when they come in contact with 
a patient ill of the disease. Even the fetus in utero may be attacked by 
measles by means of the maternal blood, and the aged also are subject to the 
disease if they have never been previously exposed to the contagion. This has 
been noted in members of royal families or inhabitants of islands, in which 
for decades contagion has not appeared. On the other hand, no one is ever 
attacked by measles who has not in some manner or other come in contact with 
a case of measles, in Iceland as well as in Central Africa, i. e., in other words : 
Only a specific poison developing anew in man is capable of producing the 
disease. 

This poison only develops in man and not outside of the human organism, 
for in his surroundings it does not usually remain active very long; for even 
a residence in places in which measles patients have been previously present, 
a few hours after careful ventilation, confers no danger to susceptible indi- 
viduals. It may be that the poison, by means of directly infected body linen, 
utensils, perhaps also, for example, by a letter 1 that has been rapidly closed, 
may be transported to certain distances inside of a short period of time, in 
this way bringing about a contagion ; but without question this is not possible 
after a prolonged period. Its increase in the affected organism is very decided, 
for a single patient is capable of conveying the disease to dozens of suscep- 
tible individuals, and by a further development hundreds and thousands of 
human beings may be infected, as has occurred upon isolated islands (Faroe 

i A well-authenticated case was described in Brit. Med. Journal, June 22, 1907, by 
Hughes R. Davis. — Editor. 

624 



ETIOLOGY 625 

Islands) twice in one century, the condition having been observed by careful 
and responsible physicians. 

With the exception of individual rare cases which appear to be endowed 
with a congenital personal immunity against the disease, so that in spite of 
frequent opportunity of contagion they are never affected, there is but one 
circumstance which conveys protection from the poison, that is recovery from 
the disease. The immunity acquired in this way in most persons is usually 
permanent, it commonly lasts for the entire life. Unquestionably measles 
lias sometimes occurred several times in the same individual, but this belongs 
to the greatest rarities and does not vitiate the rule. I remember having seen 
two attacks of measles (in an interval of several years; relapses are not meant) 
in a child in which the first attack was only rudimentary. We often hear, in 
the treatment of a case of measles, that the j^atient has already had an attack 
of the disease. 

This permanent immunity is all the more remarkable as another immunity 
artificially acquired, that against diphtheria, in no other acute affection ap- 
pears to disappear so rapidly as in the case of measles. 1 

The region to which the poison first adheres in the body of the affected 
individual, how it first distributes itself, in what connection it occurs with the 
symptoms of the disease, are up to the present still unknown facts. This 
may be readily explained as we have absolutely no knowledge regarding the 
origin and nature of the contagion. All endeavors of the best investigators 
to lift the veil of this secret have remained without result. If we may con- 
clude from other analogies, the primary point of attack of the virus might 
properly be referred to the upper respiratory mucous membranes. It has not 
as yet been determined by conclusive experiments, by means of what secre- 
tions or excretions of the body the contagious principle is transmitted to the 
healthy. In the case of measles we usually speak of a fleeting contagion, but 
observations like those of Grancher do not favor the view of the immediate 
transmission of pathogenic bacteria from the sick body by means of the air. 
This investigator, in a ward in his hospital for children, by a process invented 
by him (wire boxes around every bed) prevented the individual patients from 
coming into direct personal contact with a measles patient, whereas, naturally, 
the current of air from one bed to another was not hindered. When a child 
attacked by measles was brought into the ward at the onset of the period of 
incubation, it was shown that not the neighboring children were attacked, but 
a child was affected which was attended by the same nurse as the child that 
had the attack of measles. This nurse had nothing to do with the other chil- 
dren because both the mentioned ones had been nursed while isolated on 
account of suffering from another infectious disease (scarlatina). In the usual 
course of things, naturally, those nearer the measles patient are more threat- 

1 Many of our readers may have had a different experience. Measles does not create 
such an immunity as is here claimed. It may reappear several times in the life of a 
child. Immunity from diphtheria is not caused by a single attack : on the contrary, 
repeated attacks spread over years are not uncommon. — Editor. 
41 



626 MEASLES, MORBILLI, RUBEOLA 

ened than those distant, but even here the transmission occurs more by contact 
(touch, transmission of infected substances and the like) than by the air. 
Naturally, upon close proximity the transmission by means of vaporous parti- 
cles (in sneezing, coughing and the like) is important. 

After reception of the poison by the healthy, a number of days pass before 
the first symptoms of the disease appear. This time, called the period of 
incubation of the disease, is in most individuals, in the case of measles, a 
regular period of about eleven days. This was first determined by Parnum 
on the Faroe Islands where there was frequent opportunity of studying the 
course in such patients as exposed themselves but a single time to the con- 
tagion. The exanthem usually appears exactly upon the fourteenth day after 
contagion has taken place. Later, when it was possible, by means of taking 
the temperature, to note the first onset of the preemptive period, it was 
shown that the period of incubation in a restricted sense, required the pre- 
viously mentioned eleven days. 

The general susceptibility to contagion shows a certain limitation during 
the first four or five months of life ; but even here there is no absolute immu- 
nity. I observed an undoubted attack of measles with very characteristic 
symptoms, with fever and well-developed eruption in a boy aged fifteen 
weeks, whose brother and sister, aged respectively three and one and a half 
years, simultaneously suffered from extraordinarily severe and rapidly fatal 
attacks of measles; the sister died four days after, and the brother three days 
after the appearance of the disease in the nursling. In a second case I saw 
a boy aged twenty weeks attacked by measles, with a very marked and intense 
eruption, with high fever. In both cases rapid recovery without complica- 
tions occurred. 

After the first year of life the disease is much more frequent, and from 
the second } r ear on the susceptibility is the same as later in life. 

The susceptibility which is quite general, on the one hand, and the immu- 
nity acquired by an attack, on the other hand, determine the character of 
measles as an epidemic disease. It is only an apparent disease of childhood, 
as, almost without exception, in all larger areas of population all individuals 
have had an attack of measles before they have passed beyond the limits of 
adolescence. Where measles breaks out in a population in which no immunity 
has been acquired by previous attacks, as in 1846 upon the Faroe Islands, 
every one is attacked. Among nearly 8,000 inhabitants upon the island only 
those old persons were spared who sixty years previously, while they were 
children, had passed through an attack of measles. 

The seasons of the year have only an influence in so far as there is a 
connection between a general closing of schools and kindergartens, as during 
vacation, and in other institutions for children. From this concentration of 
young children, the occasional upflaring of measles in large cities always 
renews itself if, since the last larger epidemic, a greater number of children 
who are not yet immune have grown up, so that they find entrance into the 
previously mentioned institutions, in which there is always recurring oppor- 



PATHOLOGICAL ANATOMY 627 

tunity for contagion through some child attacked with measles coming from 
an infected district of the city. Thus, as Medical Director of a district, I 
formerly had an opportunity in April, May and June .as well as in October 
and November, to observe marked epidemics of measles. The older children 
bring measles home from school to the younger members of the family, and 
where a population, particularly in case of the poor, live close together in 
the same street, the disease spreads rapidly from one house to another and 
from floor to floor in the same house, until many children recovering from 
the malady have become immune to the disease, the locality thereafter show- 
ing no cases for several years. The same conditions prevail in smaller cities 
and villages in the case of all the children in certain districts. 

The same phenomenon is noted in the wards of a children's hospital 
unless it is especially protected. A child is admitted on account of catarrhal 
affection which is not recognizable as belonging to measles and on the eleventh 
day an epidemic occurs in the ward, attacking all children that have not been 
protected by a previous attack. Here the results are much more serious 
than in the city, for in the hospital the affection attacks children that are 
already ill from other causes, producing secondary measles, the disease then 
being far more serious. 

PATHOLOGICAL ANATOMY 

The anatomical examination of children that have died of measles does 
not give the slightest clue regarding the nature of the disease. The parts 
of the body and the organs which during life have shown distinct deviations 
in form and color as well as in function at the autopsy show no alterations 
which characteristically differ from catarrhal and inflammatory phenomena 
in the same parts in a number of other affections. In the skin the dilatation 
and tense congestion of the small veins and capillary nets of the cutis are 
recognized, which may be assumed from the clinical symptoms. Along the 
walls of the smallest veins leukocytes are found arranged in rows, the lymph 
channels are wider, the skin succulent, and disseminated foci-like collections 
of round cells are present in many areas of the cutis. The entire inflamma- 
tory or vaso-motor change of the skin in measles appears particularly to 
attack the upper layers nearest the epidermis in which cutaneous vascular 
nets are present. The hair follicles and sebaceous glands are surrounded 
by great numbers of capillaries; the infiltration of these structures is prob- 
ably the cause of the nodular prominences which characterize the eruption 
of measles. 

The catarrhal process in the respiratory mucous membrane perhaps shows 
anatomically a somewhat greater intensity in that the vascular system of the 
submucosa is more markedly implicated and the extra-vasal infiltration of 
the mucous membrane is greater than in ordinary catarrhal processes. This is 
of especial importance in regard to the course of the catarrh of the ears and 
of the larynx. When the catarrhal affection enters the finer and finest bronchi 



628 MEASLES, MORBILLI, RUBEOLA 

there is an early development of interstitial cellular infiltration of the peri- 
bronchial and perivascular connective tissue. 

Almost always — especially in the severer rapidly fatal cases — (as in many 
acute infections of infancy) a very decided cellular hyperplasia of the entire 
lymphatic system develops. All peripheral and internal lymph glands and 
other conglomerations of adenoid substance such as the pharyngeal and pala- 
tine tonsils, the solitary follicles at the root of the tongue, walls of the 
pharynx, and throughout the entire intestinal tract such as Peyer's patches 
of the ileum, are found to be in a condition of intense medullary swelling, 
so that an inexperienced observer not infrequently, especially upon viewing 
the lower parts of the small intestine, erroneously supposes enteric fever to 
be present. The acute hyperplasia of the spleen in measles is as a rule less 
developed. 

Whether this marked cell infection of the lymphatic organs which occurs 
in a few days is in connection with the regular appearance of leukocytosis 
in measles has not yet been determined with certainty. [In uncomplicated 
measles leukocytosis does not occur. — Ed.] At all events, in the child, even 
in cases in which the number of leukocytes is not markedly increased, the 
blood picture is altered in the manner that the lymphocytes are decidedly 
less than the polynuclear leukocytes. Large forms of these, such as mast 
cells, some authors have met with more frequently in the blood of measles 
than elsewhere. 

The heart occasionally shows implication from the poison of measles, 
especially the endocardium is not rarely involved, whereas the pericardium 
is not so liable to become affected. The myocardium may also occasionally 
be damaged by the poison. 

The vascular twigs and the parenchyma of the kidneys are less frequently 
damaged than in the case of scarlatina, however, occasionally the renal struc- 
ture is attacked and then shows conditions that occur in scarlatina. 

The pathological alterations of the lungs will be considered in describing 
the deviations from the normal course of the disease. 

CLINICAL PICTURE OF MEASLES 

In measles it is practical to differentiate various phases or stages of the 
clinical course which may be distinctly recognized at the bedside. 

After the stage of incubation which was explained above, the catarrhal 
stage follows, this is succeeded by the eruptive stage, and this, again, by the 
period of convalescence. The catarrhal stage is also designated as the stage 
of invasion, and, formerly, the name prodromal stage was given to it. The 
stage of eruption is spoken of as the stage of bloom or florition. 

These individual periods often find a very characteristic expression in 
the picture of the temperature curve. Thus, in one of the following charts, 
that of a boy aged twenty-one months, the fever, which accompanied the 
mucous membrane affection in the catarrhal stage, showed a curve of three 



CLINICAL PICTURE OF MEASLES 629 

days with two remissions; from the fourth to the seventh day a continued 
fever followed during which the exanthem appeared over the entire body, and 
after complete development of a cutaneous eruption the temperature fell in a 
critical manner, entering upon the stage of convalescence. (Compare the two 
following temperature curves, Figs. 20 and 21.) 

The character of the fever — remittent in the first days, highest and most 
continued during the development of the eruption and falling rapidly after 
the complete development of the eruption — is noted in all typical cases of 
the disease and, even in regard to decisive exacerbation and remission in the 
various phases of the course as well as in regard to the absolute height of 
the fever, the greatest variations occur. That there is a connection between 
the highest temperature and the greatest intensity of the eruption, as was 
previously mentioned, can only be decided with certainty by one who has 
observed a great number of cases, as well in regard to the eruption as to the 
continued temperature course. This has not been carried out by any one as 
yet; and it scarcely appears to be of practical importance. But it is impor- 
tant to note whether or not the characteristic course of measles is shown; 
to observe this through the most manifold variations is hardly difficult to the 
trained clinical eye; to deny it means to disregard a well established fact in 
a very careless manner. I am of the firm opinion that some day the discovery 
of the poison of measles will clear up the clinical type of the affection in 
the same fortunate manner as in the case of malaria. 

In connection with the fever we shall first describe the regular course of 
the affection. 

The period of incubation of measles is usually free from symptoms, devia- 
tion from this rule w T ill be described later on. 

The onset of the disease is but little characterized and differs only slightly 
from an ordinary bronchitis. In daily practice the chronology of the whole 
course is much more difficult to determine than in the case of scarlatina or 
even diphtheria, because the parents are not able to say exactly when the 
" coryza " began. Only where — in a previous illness — the temperature of the 
child has been taken from the beginning of the disease (as in charts 20 and 
21) is the rise in temperature above the normal noted from the onset (early 
in the morning in the rectum above 99.5° R, in the evening over 100.5° F.), 
even though the child very often shows no distinct subjective disturbances 
in its general condition. 

In cases where this is absent there is no reason, even for very anxious 
parents, to send for a physician. This only occurs upon the appearance of 
an exanthem and thus it happens that the practitioner often enough does not 
have an opportunity of observing the first or the catarrhal stage of measles; 
and even in cases in which he takes regular records of temperature, he only 
notes the second half of the above chart as a fragment of the entire tempera- 
ture course of the disease. 

"Where there are distinct symptoms on the part of the mucous membranes 
these consist of coryza, discharge from the nose, sneezing, swelling of the 



f>.°,() 



MEASLES, MORBILLI, RUBEOLA 



nasal passages, disturbance of sleep; in small children shortness of breath, 
and occasionally severe epistaxis. To this is added — which is quite rare in 
ordinary coryza — a sense of pressure in the eyes, causing rubbing, injection 
of the conjunctivas, lachrymation, and photophobia, so that the children ask 
to have the room darkened. The cough is often quite characteristic of 
measles; it is dry and paroxysmal and sounds harsh without any signs of 



June 

1884 


2G 


2: 


28 


29 3 


1 


2 


3 


i 


5 


6 


7 




T. 






I 


11 1] 


I IV 


V 


VI 


VI 


VIII 


IX 


X 




Fahr. 
104.0° 

102.2° 

100.4° 

98.6° 






















f\ 




A 




l\ 






Cent. 
-40° 

- qq° 
















\ 


[ 


J 




V - 




\ 


A 












i 


* 


u 


( J 


H Y 














\ 






-38° 

-S7° 


•» 


^ 


i 


) 




V 




















L 


<• 




\ 


i 


































Catarrhal 
Stage 


Exa 


ithematoua 
Stage 


Convales- 
cence 





Fig. 20. — Temperature Chart in Measles. 



" looseness/' Finally, the voice is muffled or is hoarse from the onset, which 
may always be referred to a superficial catarrh of the larynx. Not always 
are all of these cardinal symptoms present, often only one or the other, and 
then only to a very slight extent. A possible disturbance of the general 
condition is shown in younger children by irritability and crying, in older 
ones by loss of appetite, lassitude, occasionally by chilliness or chills. Finally, 
not rarely, vomiting may occur as an initial symptom. 

None of these complaints or difficulties has a well developed plastic char- 
acter, but, rather, at least in the majority of cases, are only feebly developed. 

The objective examination, if there be an opportunity to make one, does 
not show specific lesions in the diseased mucous membranes. The conjunc- 
tivae are often intensely swollen and reddened, mucus and pus are excreted, 
and stick to the lids, thus causing difficulty in opening the eyes, but a macular 
character of the redness cannot be noted. If at all present, this is met with 
in the mucous membrane of the palatine arches and upon the tonsils, but 
only toward the end of the catarrhal stage shortly before the appearance of 
the eruption. 

All the more valuable, therefore, is a phenomenon which, although not 
absolutely characteristic of measles (by some authors also noted in rotheln), 
is of importance for the eruptive character of the catarrhal process of the 



CLINICAL PICTURE OF MEASLES 



631 



mucous membranes. This is the whitish spots found upon the inner surface 
of the cheeks, behind the angle of the mouth. This name may be given to 
them, as Koplik, who accurately described this symptom, states that they 
appear like fine specks of lime upon the reddened mucous membrane. These 
spots, found upon reddened areas, are about the size of the head of a pin, 
raised above the mucous membrane, disseminated, few or many in number, 
and of a bluish-white or yellowish-white appearance. Sometimes they can 
only be seen with a good oblique light, but if this area is examined they 
are often found to be quite prominent. Sometimes they resemble beginning 
aphthae. These spots cannot be wiped away, and if the white deposits are 
scratched off they are shown to be collections of epithelium which are per- 
meated by a turbid mass of detritus. They have previously been described, 
for example, by Reubold, a pupil of Rhimecker, by Filatow, and others, and 
they are also mentioned in Gerhardt's text-book, but their diagnostic impor- 
tance and their regular appearance on the first days of measles was first 
clearly shown by Koplik. They are a very frequent prodromal symptom, and 
in my clinic were noted in six-sevenths of all cases. 

The symptoms of invasion last three days. Toward the end of this first 
stage, not infrequently before the cutaneous eruption, there appears upon the 
mucous membrane of the palate an exanthem which consists of individual, 
deep red serrated spots, separated from one another, inside of which the 
swollen solitarv follicles are noted as individual nodules. This redness which 



June 
1884 


27 


28 


29 


30 


Ju]y 
1 


2 


3 


4 


5 


6 


7 


8 


9 




T. 






I 


II 


III 


IV 


V 


VI 


VII 


VIII 


IX 


X 


XI 




Fahr. 
104.0° 

102.2° 

100.4° 


























/ 


A \ 




1 


A 




> 
















Cent. 
40° 

39° 

o 

38 






















*\ 


v 


1 




V 










\ 


V 




















£ 


y 


/ 


A 


y 


/ 






















N 


V 


\ 


V 






/ 


A 


V 


/ 


















































Catarrhal 
Stage 


Exautliematous 
Stage 


Convalescence 





Fig. 21. — Temperature Chart in Measles. 



is sometimes confluent and only serrated at the borders occurs particularly 
in the velum of the palate, but thence distributes itself to some distance 
over the mucous membrane of the hard palate and but rarely, when quite 
distinct, affects the tonsils, for example, the surface surrounding the lacuna. 
This eruption on the palate disappears more rapidly than the cutaneous 
eruption. It is not of great importance for the diagnosis of measles to rec- 



632 MEASLES, MORBILLI, RUBEOLA 

ognize this prior to the eruption of the cutaneous exanthem, as it usually 
only appears with this or at least precedes it only by a very brief period. 

Upon the evening of the third day or during the succeeding night the 
first macules appear upon the skin, most frequently upon the face or about 
the eyes and mouth, upon the temples and behind the ears. But quite regular 
cases occur in which the first delicate macules are seen upon the back, whereas 
the head and face are still free from the eruption. The macules rapidly 
increase in number and enlarge by coalescence of the smaller and larger 
spots and now appear upon the entire surface of the body. A distinct sequence 
of individual parts of the skin may be noted, thus, after the head and neck, 
the upper trunk and upper arms, then the lower trunk, buttocks, thighs, and, 
finally, the forearms, lower legs and feet are attacked. The rapidity with 
which the entire body is covered varies greatly in individual cases, upon the 
average the maximum of the exanthem is reached in from a day and a half 
to two days. Upon its first appearance the individual macule of measles is 
small, scarcely of pin-head size, of a light red color, and round, sometimes, 
however, even upon its appearance it is of an irregular shape, oval, indented 
and also serrated. It is not raised above the level of the skin and in children 
with very white skins it is sharply defined. However, the character of this 
macule changes rapidly. It becomes darker red, dull brown, and larger, 
several neighboring macules being combined, and only now does the charac- 
teristic appearance of the eruption of measles appear : Lentil-sized, and larger, 
irregular, serrated, crescent-shaped macules inside of individual ones, in the 
larger macules mostly three or four conically pointed red millet-seed nodules 
are seen and felt. The nodules often correspond to hair follicles or to the 
mouths of sebaceous follicles. These glands secrete more profusely than nor- 
mal so that the affected cutaneous areas have a slightly greasy feeling. The 
entire macule is now raised above the surface of the skin (morbilli elevati ; 
cases in which this nodular elevation is slight or absent are known as mor- 
billi laeves). 

Occasionally in place of the nodules, particularly upon the back and chest, 
vesicles are formed, then a large number of small spots are found which carry 
a vesicle in their centre, the exanthem of measles then resembling miliaria. 

The whole appearance of the measles patient shows distinct macules at 
the height of the eruption, the entire skin from head to foot is covered 
with closely adjoining individual points of the eruption. As the eruption 
in each part of the body remains at its acme for quite a time the total dis- 
tribution of measles may be easily observed. Xo part of the skin remains 
free, the hairy head and ears as well as the genitalia being covered with the 
eruption. The back of the hands and the soles of the feet are shown to be 
most markedly affected. 

Upon the trunk and upon the buttocks most frequently — but this phenom- 
enon also occurs upon the face and the extremities — the appearance of the 
eruption is also altered by the fact that sooner or later the individual serrated 
macules extend beyond their limit and completely coalesce, forming large 



CLINICAL PICTURE OF MEASLES 633 

clusters. This gives these wide cutaneous surfaces an appearance of being 
uniformly covered by a connected eruption, the consistence differing quite 
markedly from the spotted skin of ordinary measles. Confluent measles is 
then spoken of. That these have, however, occurred secondarily from the 
above-mentioned characteristic macules can always be noted upon closer exam- 
ination, for individual, completely white, usually somewhat serrated cutaneous 
areas have remained in the midst of this connected mass of redness. 

An appearance which is not rare in a quite regular course of the disease 
consists in the fact that more or less distributed areas of the cutaneous erup- 
tion become hemorrhagic. This occurs particularly upon the cheeks, fore- 
arms and buttocks, but it may also occur upon any other part of the body. 
That the vascular change in the macules of measles is combined with a greater 
permeability of the vessel walls permitting the hemoglobin to pass out (whether 
this be in the form of the erythrocytes themselves or in the form of dissolved 
hemoglobin from the corpuscles) may be concluded from the pigmentation 
of the macules of measles, which for days and even for weeks permit us to 
still recognize the character of the eruption which has already faded. Not 
rarely do massive extravasations of blood occur in the area of the eruption. 
Then the exanthem takes on a dark bluish-red color which gradually turns 
green or } r ellow, exactly like any other cutaneous hemorrhage. The change 
also preserves the exanthem for a long period even into convalescence. This 
deviation which is without importance for prognosis must not be confounded 
with the cyanotic appearance of the cutaneous eruption which is always of 
serious import and which will be described later on. 

It is unquestionable that the patient during the acme of the eruption 
emits a peculiar odor which is variously described by different observers. 

"With the development of the exanthem the complete disease reaches its 
acme. The temperature at its highest grade reaches 104° F. and often above 
10-1 F., sometimes above 105.5° F., even in ordinary cases, and even during 
the morning hours of the worst days no remission occurs. In a regular 
course of the affection the pulse corresponds to the fever without reaching 
disquieting heights. The general condition and the nervous system are now 
markedly implicated in the process. The appetite is entirely gone, the patient 
becomes apathetic toward his surroundings and his own sensations, toward 
night somnolence changes to irritability; complaints of headache and pains 
in the limbs, and not rarely delirium, often of quite severe type, may be 
noted. 

All catarrhal phenomena increase. The mucous membrane of the eyes 
secretes more markedly, and during the night the eyelids become aggluti- 
nated, and can only be opened with great pain and then marked photophobia 
is present. The nose secretes purulent mucus, which excoriates the nasal 
openings and the upper lip. Now and then herpes develops about the mouth. 
The hoarseness is of a high degree; soreness in the larynx or along the 
larger bronchi is disturbing, but the dry cough which is almost continuous 
is particularly troublesome to the little patient weakened by fever. 



634 MEASLES, MOHBILLI, RUBEOLA 

Physical examination shows the existence of a bronchitis of the larger 
tubes. 

The tongue is covered by thick, whitish, viscous masses which during 
the acme of the disease are often desquamated in serrated flakes so that the 
smooth red mucous membrane of the tongue is visible beneath. Upon the 
gums and upon the mucous membrane white deposits appear while the exan- 
them upon the mucous membrane disappears. Occasionally the eruption upon 
the skin is accompanied by a paroxysmal diarrhea, as a rule, however, consti- 
pation is present. 

All the lymph glands of the neck, throat, axilla and inguinal region often 
enlarge decidedly, the glands may even become painful. 

The urine becomes scant, concentrated, shows a sediment and, with a 
high fever, not rarely contains albumin. Various finer alterations in its 
composition point to disturbances of metabolism at the height of the disease; 
thus, the regularly and very markedly developed diazo-reaction which occurs in 
measles, the appearance of copious amounts of diacetic acid, of propeptones, 
allow of the conclusion that under the influence of the poison of measles 
the decomposition of albumin bodies of the organism occurs in a different 
manner than under normal circumstances. 

Of the alterations in the morphology of the blood, mention has already 
been made; they point to the circulation of foreign toxic substances. That 
the blood during measles becomes rich in measles antitoxin, Weissbecker 
believes to have proven by experiments, in having cured severe cases of 
measles by the inoculation of serum from persons having recovered from 
that affection. An interrogation point may well be placed after this state- 
ment. 

The description given above corresponds to the picture of the well devel- 
oped intense but uncomplicated affection. In individual cases, in general 
practice, the accompanying phenomena are often much less developed even 
in instances in which the eruption, as is often the case, is well marked. 

In the majority of cases, it is, however, characteristic that the disease 
develops progressively up to the maximum of the eruption so that the severest 
period corresponds about to the time at which the exanthem is in full bloom. 

From point to point the combat between the organism and the poison of 
the disease takes place. The areas involved become more numerous, the con- 
dition is more and more threatening until a halt occurs which takes place 
rapidly and suddenly in the measles process. 

During the same night in which the most severe delirium is present, in 
which the troublesome cough disturbs sleep, the swelling of the eyes and nose 
gives rise to the greatest discomfort and when the fever is almost unbearable, 
the entire picture changes suddenly; fever falls, the child sleeps, the cough 
becomes looser and sweating appears. Upon the next morning the child is 
without fever, and has a clear mind, appetite begins to reappear and he, is 
ready again to play with his accustomed toys. 

Thus the patient with a rapid defervescence of the fever, which in uncom- 



DEVIATIONS FROM THE NORMAL COURSE 635 

plicated cases often lasts a day and a half instead of half a day, reaches 
the third period of the affection, the period of convalescence. That this 
must still be looked upon as belonging to the disease and cannot be desig- 
nated as a return to health, is founded upon the fact that during the period 
of defervescence symptoms exist which only slowly disappear and that it is 
particularly this period in which a great number of complications and sequels 
originate. 

The catarrhal symptoms are those which now slowly disappear. The con- 
junctiva still secretes for a little time, the e} r elids still suffer from the influ- 
ence of the secretion, blepharitis ciliaris occurs, slowly the coryza diminishes, 
but still a number of clays must intervene before the voice becomes clear and 
cough gradually disappears. 

The skin shows a tendency to sweating while the exanthem is disappear- 
ing and a pigmentation which has remained fades either rapidly or slowly. 
The skin is still very sensitive to refrigeration, its effect is regularly shown 
by an implication of the mucous membranes particularly those of the respi- 
ratory system. 

Besides this, a peculiar late effect of the poison of measles makes itself 
felt: namely upon the heart. The frequent pulse, corresponding to the rise 
in temperature, falls simultaneously with the fever and now becomes abnor- 
mally slow and irregular. The exact character of this irregularity has not 
yet been studied; this arrhythmia disappears after a few days without a 
permanent injury to the heart remaining behind. 

The duration of the period of desquamation cannot be given with absolute 
certainty. There is no absolute indication by which we may determine the 
return of complete health and normal resistance. Temperature taking is of 
no avail here for, as has already been mentioned, the period of convalescence 
lasts for days and in some cases perhaps for weeks longer than the period 
of defervescence. 

In practice rather than to regard this period as too brief, it will be well 
to prolong it and to consider it as continuing as long as there are still signs 
of an acute catarrh of the mucous membranes. 

From this, the described picture of the regular course of measles, there 
are a number of complications and deviations, in those concrete cases, the 
discussion of which alone gives a correct idea of the actual condition of the 
process in measles. 

DEVIATIONS FROM THE NORMAL COURSE 

Even during the period of incubation, symptoms may appear, in contrast 
to the undisturbed health which is usually present. Occasionally this may 
depend upon accidental conditions, upon catarrhs or other deviations from 
health which may be due to other causes, such as ordinary colds, influenza, 
whooping cough, etc. But there are still quite a number of cases in which 
the infection of measles even during this time makes itself felt by quite a 



636 



MEASLES, MORBILLI, RUBEOLA 



Dumber of disturbances. This may be recognized from the fact that these 
symptoms arise during the time at which, according to calculations — for 
example, the opportunity for infection, the later appearance of the eruption 
— the infection must have taken place. 

These are particularly slight rises in temperature, which are noted in 
children in whom regular temperature observations are undertaken because 
it is suspected that they have become infected. Without showing any symp- 
toms of disturbance in health, during some days, or in the evening, occasion- 
ally for several succeeding days, temperatures of 100.6° F. to 101.1° F. may 
be noted in the rectum, with this the daily variations are slight and even in 
the morning the temperature may reach 100.2° F. to 100.4° F. 

In other cases, simultaneously with the slight rises in temperature, the 
children show other symptoms, particularly disturbances of the same kind as 
those occurring in the prodromal or catarrhal stages of the disease, but of 



March 

1886 


7 


S 


9 


10 


11 1 


2 13 14 


15 16 


17 18 


19 20 


T. 










I I 


I III IV 


V VI 


VII VIII 


[X X 


Fahr. 
104.0° 

102.2° 

100.4° 




















A 


Cent. 
40° 














a A7 




t 


A, 


•W° 










Ia 


W 




f 


L 


-A n° 








A 

i 


/' 


7 + 


T^ 






\ 


f \ , 




Incubation 


Catarrhal 1 
Stage 


^xanthomatous Coi 
Stage c 


lvalea. 
ence 



Fig. 22. — Temperature Chart in Measles. 



less intensity, for example, coryza, slight catarrh of the conjunctiva, bloated 
face, eyes filled with tears or the like. These symptoms disappear and only 
then, with well developed fever and distinct catarrhal phenomena, does the 
actual disease begin. 

In this manner the disease runs its course, as is shown in the above 
temperature chart (Fig. 22). 

Where there is no opportunity to measure the fever during the period of 
incubation, we are told that in a case of this kind catarrhal symptoms have 
been present for a long time. Very frequently the parents state that cough 
has been present for a number of days previous to the onset of the disease, 
which began with pain in the eyes and running of the nose. 

It may be readily understood that the catarrhal phenomena and, even- 
tually, also, mild fever are subjectively somewhat more pronounced during 
the period of incubation, but the chronology of the onset of the disease cannot 



DEVIATIONS FROM THE NORMAL COURSE 637 

be determined with certainty from the statements of the patient. Thus, it 
may be explained that parents say the child has not been well for six, eight or 
even fourteen days before the appearance of the eruption. Only occasionally 
does the infection itself appear to be introduced by a febrile period of brief 
duration which then gives way to an undisturbed period of latency. 
An example of this is shown by the following case : 

A girl aged seven years, taken ill on October 27th with pains in the throat and 
lachrymation. Early upon October 24th there was a temperature of 102.2° F., in the 
evening 103.2° F. Upon October 25th a temperature of 101.1° F. ; nothing but a slight 
redness of the palate could be recognized. Upon October 26th, a temperature of 
100.8° F., then complete health; the child returned to school. Upon November 1st, 
therefore, twelve days later, the prodromes of measles appeared and upon November 
4th the exanthem of measles was seen. 

In an adult aged twenty-five years, ten days before the appearance of the 
eruption, I once noted severe arthritic pains, beginning in the ankles, then 
occurring in the knees, shoulders, elbows and hands, later attacking the sacral 
and lumbar regions, and being accompanied with an irregular, not very high 
fever. With the appearance of a very intense exanthem of measles all pains 
suddenly disappeared. 

The invasion, or so-called prodromal period, of measles is often charac- 
terized by very slight symptoms. Catarrh of the eyes, nose and trachea are 
then of a minimal nature, as in a very slight coryza, or they may not even 
be noted at all. There are cases of this kind where the deviation from the 
normal can only be recognized when regular temperature observations are 
taken. Where this is not the case the parents very properly assert that the 
child was quite well prior to the appearance of the eruption. If, thereafter, 
the entire affection is very mild and also the fever which occurs during the 
eruption is of brief duration and slight, even the most experienced may 
come to the wrong conclusion that he is not dealing with measles at all but 
with rotheln. 

On the other hand, the disease ma} r begin with unusual, severe disturb- 
ances in general health. This occurs particularly in very young children, 
those up to two years of age, then a rapid, high, continued fever appears, 
occasionally being ushered in by convulsions, intense catarrh, vomiting, diar- 
rhea and coma. This severe condition lasts for several days of the measles 
process and is often enough followed by severe complications; but these high 
febrile prodromes are not necessarily of bad prognosis; sometimes after the 
appearance of an intense eruption defervescence occurs in the ordinary period 
of time. 

Sometimes the initial disease of the mucous membranes appears with 
extraordinary severity. The conjunctival catarrh assumes the character of 
a true blenorrhea, the dry swelling of the mucous membrane becomes so 
marked that the children develop a loud sniffing, dyspneic type of respiration 
(prognostically an unfavorable sign), or the muco-purulent excretion is so 
profuse that the children lose their rest from the alternate contamination 



638 MEASLES, MORBILLI, RUBEOLA 

and cleansing of the parts. Occasionally very severe epistaxis occurs, being 
so marked that tampons are necessary. The transference of the disease of 
the mucous membranes to the Eustachian tube and. to the tympanic cavity 
may even occur in the prodromal stage. The submucosa of the larynx may 
be so greatly swollen that serious symptoms of pseudo-croup may usher in 
the disease; the tracheo-bronchitis may give rise to severe difficulties, par- 
ticularly causing disturbing cough. 

Occasionally foreign symptoms develop. Prodromal eruptions appear, with 
particular frequency resembling those of miliaria. Occasionally the skin, 
particularly in cases of children with valvular disease, takes on a peculiar 
marbled appearance before the beginning of the eruption. Sometimes urti- 
caria-like eruptions appear. In children who suffer from slight dry eczema 
of the face, the affected areas show a peculiar macular measly appearance 
one or two days before the true eruption begins. 

In place of the catarrh of the upper respiratory mucous membranes or 
simultaneously developed with this, there is sometimes a simple or purulent 
inflammation with occasional swelling of the lymphatics at the angle of the 
lower jaw, then the prodomal fever is higher than ordinary. 

Finally the catarrhal stage of measles is now arid then abnormally pro- 
longed without other symptoms appearing. Thus it may occur that five, six, 
even seven days pass before the cutaneous eruption becomes pronounced. 
Often upon the fourth or fifth day it seems as if the eruption would appear, 
for around the eyes or nose quite sparse, pale non-characteristic macules 
appear, but they do not become distinct ; the eruption tarries until, finally, 
two or three days later a distinct and marked exanthem arises, which then 
usually very rapidly implicates the entire body so that the whole process, 
nevertheless, is not particularly prolonged. Such an extended prodromal 
stage always shows fever, this is usually of a remittent type, occasionally, 
however, it may be of a high continued character. So long as the investiga- 
tion of such cases shows no objective or subjective signs (for example dysp- 
nea) pointing to an internal complication, there need be no fear on account 
of the tardiness of the cutaneous eruption. Often this condition is followed 
by very dense confluent or even a hemorrhagic form of the exanthem. 

Deviations from the regular course, having a serious prognostic import, 
are quite rare during the period of invasion or prodromal stage, and for this 
reason also a separate examination of this stage of the disease is of value. 
Such complications occur in both of the following periods, that of the erup- 
tion and that of defervescence. In these, however, in the main the nature 
of the serious changes are not equal. In the period of eruption the great 
catastrophes occur, the breaking down of the resistance of the entire organ- 
ism; in the period of defervescence the attacks of individual parts which at 
the onset show but slight damage of separate organs or parts of organs which, 
however, by distribution over large areas or invading deeply gain an ominous 
importance. 

Regarding the period of eruption, deviations in the form of an especially 



DEVIATIONS FROM THE NORMAL COURSE 639 

mild course are to be noted. In a general, mild affection the cutaneous erup- 
tion may be slight and of a fleeting character, whereas, simultaneously, all 
other phenomena disappear rapidly. There are even infections with measles 
of a benign character without an eruption ; this is shown by the following 
clinical history. 

Hessel, Max, aged three years, taken ill. during the night from January 27th to 
28th, with fever, laehrymation. conjunctivitis, headache. Upon the evening of January 
30th, temperature 104° F. January 31st. 101.3° F. in the morning. 104.5° F. in the 
evening. February 1st. 101.5° F. Nothing could be determined: there was marked 
swelling and redness of the eyes and coryza, evening temperature 102.9° F. February 2d. 
temperature 101.7° F., early in the morning, continued complaints of the eyes, and 
headache: marked coryza, cough. Evening temperature 102.6° F. February 3d. 
101.5° F., pulse 156. Very restless during the night, much cough, with nausea: evening 
temperature 103.6° F. February 4th, 100.8° F., condition the same. Posteriorly, over 
both lower lobes bronchial rales, also some fine rales, evening temperature 101.1° F. 
February 5th, 100.9° F., in the evening 102.2° F. February 6th, 100.2° F., thence on 
afebrile course. Complete recovery. 

Early upon February 13th, that is, about thirteen days after the onset of the dis- 
ease, his brother George, aged one year and a half, showed a typical eruption of 
measles. Max, who had not previously had measles, was not attacked. 

In this case, therefore, we are dealing with a febris morbillosa sine mor- 
billis (similar to conditions in other acute exanthemata, such as scarlatina and 
variola) . 

The serious changes during the period of eruption are more important; 
among these are first to be mentioned those, fortunately rare, cases with a 
rapidly fatal course. They are analogous to conditions which we meet in scar- 
latina and other acute infectious diseases and are probably the expression of 
a most intense intoxication with the virus of measles, or of a lowered resistance 
of the cells of the body to the poison. Since we have learned, especially by the 
labors of Ehrlich, PfeirTer and others, to appreciate the methods by which the 
organism protects itself in the combat with bacteria and toxins, this explana- 
tion can no longer be looked upon as a mere phrase. 

In these cases, as, ordinarily, the disease begins with muco-purulent ca- 
tarrh : in some of my cases high fever was present from the onset, in others the 
temperature rose gradually. However, from the beginning a marked implica- 
tion of the sensorium is conspicuous. The children, even during the period of 
invasion, become decidedly apathetic, sleepy, and lie in bed with their eyes 
closed, these being often markedly swollen: they have neither appetite nor 
thirst. Upon the fourth or fifth day of the disease there appear upon the 
back or other parts of the trunk, some sparse, pale, not very distinct macules, 
which do not become more developed during the next few days. In spite of 
this, the fever rises, apathy alternates with nervous unrest: trembling of the 
extremities, a staring look and strabismus appear : lips and tongue become dry 
and fuliginous, and now, after a period of from seven to eight days, severe 
convulsions lasting for hours terminate life, or even without this, death 
occurs from nervous exhaustion. In the lungs, in some cases, the onset of a 
bronchitis of the finer tubes may be noted, but this is by no means always 



640 



MEASLES, MORBILLI, RUBEOLA 



the case. Whereas the cutaneous exanthem remains up to death in the unde- 
veloped condition which has been described, in other cases it develops with 
great intensity, in that fever and nervous symptoms increase in the same 
manner as in the absence of the exanthem. I have seen this fulminant course 
leading to death but a very few times, and especially in very young children 
under one year of age ; once I saw it in a seven months old nursling. 

The autopsy in these cases does not show the cause for the fatal issue. In 
those cases in which marked convulsions occurred prior to death, there are 
found cerebral edema and cerebral hyperemia; in the bronchi the first stages 
of catarrhal implication, in the form of decided reddening of the mucous 
membrane and clogging of the lumen with hyaline mucus; the heart is already 

in a condition of dilatation, but 
the most conspicuous sign is the 
previously mentioned high-grad- 
ed swelling of the solitary 
follicles and Peyer's patches 
throughout the entire intestinal 
tract. The spleen is acutely 
swollen and pulpy, with enlarged 
Malpighian bodies. Liver some- 
what anemic, partly showing 
fatty infiltration. The kidneys 
in a condition of cloudy swell- 
ing of the parenchyma. In the 
main, therefore, we find the 
same picture which we meet 
in other severe infections ; and we cannot doubt that in these cases the intense 
action of the poison of measles causes the fatal termination. The temperature 
curve (Fig. 23) gives an example of such a malignant course of measles; it is 
that of a nursling aged seven months, in which the autopsy showed marked 
cerebral edema and the above-described conditions (Fig. 23). 

A second form of the catastrophe in the stage of eruption is that much 
more frequent variety which is known to every observer and which is not 
incorrectly designated by the laity when they say : The measles have " struck 
in." In fact we are dealing here with a condition of the eruption which resem- 
bles the sudden decay of a blossom. This condition also occurs most usually in 
young children in the first year of life. The stage of invasion either runs its 
course without special symptoms giving rise to fear, or the mere change may 
be suspected in so far as the little patients become unusually short of breath 
and present the previously mentioned sniffing respiration, with swollen nose, or 
show great unrest with high fever. Now the exanthem appears, develops first 
in the face, neck and chest, according to rule — but suddenly the further de- 
velopment of the eruption and the intense dark redness of that which is already 
prominent, rapidly declines and takes on a paler blue or even an intensely 
cyanotic appearance. Or the eruption distributes itself over the body, but in a 



May 

1890 


2 3 


4 5 6 


7 8 9 


10 




T. 


1 II 


III IV V 


VI VII VII 


J 




105.8° 
104.0° 
102.2° 








A 






41° 
40° 

39° 








/ 
/ 










/\ 


/ 
L 








A 












Exanthem 





Fig. 



23. — Temperature Chart in Malignant 
Measles. 



DEVIATIONS FROM THE NORMAL COURSE 641 

feeble undeveloped form, showing an indistinct bluish color with indistinct 
demarcated contours, irregularly limited to individual cutaneous areas. Dur- 
ing this period the child seems to wither, becomes decrepit, has hollow eyes, 
cyanotic lips and extremities; only the respiratory function is stimulated and 
increased. Dilatation of the alae of the nose, increased respiratory frequency, 
marked action of the intercostal muscles, besides the movement of the lateral 
thoracic region, retraction above the region of the insertion of the diaphragm, 
sometimes general stenotic inspiratory retraction in the jugular and supraclav- 
icular spaces and epigastrium, which almost resemble croup : all this points to 
a severe implication of the bronchi and the lungs. Examination shows the 
signs of a gradually extending capillary bronchitis; the heart becomes weaker 
and weaker, and often with the addition of convulsions, sometimes also of pro- 
fuse diarrhea, whereas the entire skin becomes flaccid and from the eighth to 
the tenth day of the disease the fatal issue results. The autopsy then shows 
the cause of the respiratory affection to be a disseminated inflammation of the 
mucous membrane of the entire bronchial tree, contrasting markedly with the 
pallor of the skin. A large number of the finest bronchi are plugged with muco- 
pus and the onset of the inflammatory and atelectatic changes in the lungs can 
always be determined. The entire process in fact gives a complete impression 
that the poison of measles, which under normal circumstances produces inflam- 
matory changes in the skin, has taken a false passage and has implanted itself 
upon the mucous membrane of the bronchial tree. From this first form of 
the fulminant fatal course, a second one is differentiated in that here a proper 
resort to treatment may favor the regular localization of the measles poison, 
whereas in the first instance all therapy is unavailing. 

To these general catastrophes I should like to add a third which particu- 
larly implicates the lungs, but which in the main is but little recognized, and 
which, in my opinion, must also be referred to the severity of the measles virus. 
These cases are rare but I have met with them in several separated measles 
epidemics. They may be designated as a rapid necrotic pulmonary inflamma- 
tion due to measles. The following clinical history will exemplify the course 
of this form. 

Bode, Emilie, aged one year, both parents healthy; the child having been completely 
well up to then was attacked, on April 19, 1877, with the usual symptoms of measles, 
which simultaneously attacked another child living upon the same floor of the house and 
which in the latter child ran a regular course. With conjunctivitis, which rapidly 
took on a quite intense character, coryza and cough were present, but no distinct 
eruption appeared. Moreover, with the fever which was at times high and moderately 
remittent, on April 25th, over the right, and on April 27th also over the left lower 
lung, signs of a quite diffuse infiltration appeared which, with continuing fever, caused 
a marked decline of strength, with frequent collapse, and then attacked the upper lobe. 
The child became more and more apathetic, complete anorexia occurring, and with 
closed eyes moaned and complained. Frequent spasmodic grinding of the teeth. Quite 
severe general condition. Thus the affection lasted several weeks, until May 14th, 
twenty-six days after the onset of the disease, an eruption of measles appeared, which, 
however, upon the following day became pale and cyanotic. With increasing asthenia 
and cardiac dyspnea the child died upon the same day, May 15th. 
42' 



642 MEASLES, MORBILLI, RUBEOLA 

The necropsy showed the following: The right upper lobe of the lung was adherent 
to nearly the entire thoracic wall by firm pleuritic adhesions. As was shown by section, 
it was transformed into masses of cavities containing pus, of the size of a large hazelnut, 
which proved to be dilated bronchi with very thin walls. The pulmonary tissue lying 
between, as well as that of the middle lobe, was changed into a mellow whitish-gray to 
yellow, discolored tissue (but not caseous), in which the original structure could still 
be discerned, but which showed a decided reduction from the original volume. The 
left upper lobe was but little altered. Both lower lobes showed the usual condition of 
disseminated lobular pneumonia of a yellowish-brown color. In these lobes also a high- 
graded purulent bronchitis could be noted. The bronchial glands were markedly swollen, 
medullated, bluish-red; nowhere caseation nor miliary tubercles. Spleen decidedly 
swollen, pulpy, dark bluish-red. Both kidneys considerably enlarged, with marked 
yellowish discoloration of the cortical substance; slight intestinal catarrh. 

We see, therefore, a child previously healthy, taken ill with prodromal 
symptoms of measles, and instead of the eruption, a pulmonary affection of a 
quite peculiar character appears, which in four weeks leads to death; shortly 
before this a fleeting measly exanthem makes its appearance. Two processes in 
the severely affected lungs here act together: first, the acute necrosis of the 
tissue. (In cases occurring later I made a histological examination of the 
pulmonary tissue and found a non-nucleated appearance of the alveolar exu- 
date as well as of the original dense cellular infiltrated pulmonary tissue.) 
Secondly, a quite rapid development of bronchiectasis not so much due to an 
ulceration or suppuration as to a thinning and loss of permeability of the 
bronchial wall. Taken altogether, it is a quite acute and severe lesion which 
implicates the pulmonary and bronchial tissues to a pronounced extent. It 
was of great interest to me some time later (at a meeting of the Society of 
Naturalists in Hamburg) to see some specimens of pulmonary plague, in which 
there was the same combination of acute bronchiectasis and necrotic decom- 
position of the inflamed pulmonary tissue. 

In the epidemic of the year 1877 I saw two cases quite analogous to the 
one described, but with a still more rapid course, they were, however, not so 
pure as the ones described above, as, besides, caseous bronchial glands were 
found. In spite of this the acute pulmonary necrosis was not due to tuber- 
culosis. Later I met with similar cases from time to time. I should like to 
bring these into analogy with the acute inflammatory tissue necrosis of the 
palate in scarlatina, that refers this development directly to the poison of 
measles, for the ominous change, as already mentioned, occurs particularly in 
the beginning and at the height of the disease, at which time mixed infections 
are not so frequent. Naturally, by this it is not meant to deny that the lat- 
ter also, under some circumstances, may lead to the severest injury of tissue. 
I observed a case of necrotic pneumonia, besides maligant endocarditis with 
cutaneous hemorrhages and renal infarcts, in a nursling aged ten months. 
The entire process, however, in this case only developed fourteen days after the 
eruptive period. 

This pneumonic form of measles certainly deserves further study; it is 
sufficient here to call attention to the course, which up till now has been little 
observed. The prognosis is always ominous to the highest degree. 



DEVIATIONS FROM THE NORMAL COURSE 643 

Before leaving the description of the eruptive period of the disease, another 
variation of the exanthem must be briefly considered. The form which is of 
little prognostic importance, as well as the important rudimentary forms, the 
smooth and elevated forms, and the hemorrhagic consistence of the eruption, 
these have already been described. 

The formation of nodules in the individual macule occasionally reaches 
such an extent that the appearance of the eruption is entirely altered. In 
each macule that is at all round, a nodule occurs, but of such a size that the 
face, for example, becomes covered with dense, cloudy, markedly red promi- 
nences. The appearance of the patient will then show great similarity to 
variola. In the case of a young child, upon its buttocks which have become 
irritated by feces and urine, the nodules in the measles macules spread out, 
form lentil-sized flat infiltrations, with umbilicated surfaces, and, after the 
epidermis has become desquamated, are of a shining flat consistency, which 
may cause confusion with syphilitic eruptions. 

Sometimes the exanthem, by a special variety of confluence, shows large 
macules, the individual spots reaching the size of a ten-cent piece, even the 
size of a quarter. Sometimes irritation of the entire macule occurs, which 
then stands out above the other skin like a high plateau, the whole condition 
very markedly simulating urticaria. 

Occasionally in these large individual nodules of measles I have noted 
pustule formation, which may cause still further errors in diagnosis. The 
miliaria form of the measles exanthem has already been mentioned. 

In some cases, on the other hand, the macules permanently remain as small 
spots, without confluence, the color then remains light red and the entire 
appearance of the eruption may bear great similarity to a feebly developed scar- 
latina. 

The relation of measles to pemphigoid cutaneous eruptions is very remark- 
able, and has been lately emphasized by some authors. I am 'able to confirm 
these reports. Not only that not infrequently an eruption of vesicles resem- 
bling pemphigus appears in connection with the eruption of measles, but that 
the eruption of measles itself may appear in the form of a pemphigoid exan- 
them and run its course. 

This is proven by the following case : 

On October 23, 1881, George Schilling, aged three years, was attacked by the 
prodromes of measles, the normal exanthem following, and upon October 26th his brother 
Herman, aged seven years, was attacked in the same manner. 

Simultaneously upon October 26th, their sister Louisa, aged nine months, was 
attacked with unrest, fever, coryza, hoarseness. Temperature upon October 27th, 100.6° 
F., in the evening 101.5° F. October 28th, 102.4° F. Upon the face, upon the neck 
and upon the upper trunk a large number of warty sore spots, partly flaccid vesicles, 
filled with a thin fluid, being the size of a pea and larger and resembling pemphigus. 
October 29th, temperature 104.9° F.; the vesicles have not increased, evening tempera- 
ture 103.2° F. No measles eruption, only upon the buttocks some elevated redness. 
Evening temperature 105.1° F. October 30th, morning temperature 103.2° F., evening 
temperature 102.4° F. October 31st, temperature 101.8° F., evening temperature 99.5° 
F. November 1st, 100,4° F. The vesicles have increased and enlarged, upon the back 



644 MEASLES, MORBILLI, RUBEOLA 

some the size of a walnut are noted. Upon the buttocks and posterior surface of the 
legs a raised erythema. Evening temperature 100.6° F. November 2d, 100.6° F., upon 
the trunk a few new vesicles. Now also upon the lower thighs a few vesicles, evening 
temperature 99.9° F. November 3d, temperature 99.1° F., a few new vesicles upon the 
trunk. The old had for the most part ruptured and given rise to erosions. Novem- 
ber 4th, no fever, formation of vesicles had ceased, hoarseness still existed. 

Of interest, further, is the occurrence of a relapsing eruption in measles. 
I saw this in a girl aged four years, who in the course of a month had two 
eruptions, and a month and a half later, for the third time, showed an exquisite 
eruption of measles. 

Upon April 16th she was attacked by cough, upon April 27th conjunctivitis with 
slight fever occurred, and then upon May 1st, with but a single rise in temperature, 
to 102.7° F., an eruption appeared which distributed itself over the entire body. 

Upon May 30th, after all traces of the eruption had disappeared, a second exanthem 
occurred which was taken to be rubella. 

Upon July 15th, the child was taken ill for a third time, with headache and coryza, 
and, again, upon July 19th, a quite characteristic measlv eruption occurred which lasted 
ten days. 

What appears remarkable was that each of the attacks was conspicuously 
mild regarding fever and accompanying phenomena. Other authors have, also 
described these relapsing forms. 

The desquamation of the shin after the disappearance of the eruption is 
very slight and is often entirely concealed by the return of sweating during 
the stage of convalescence. Fine flaky desquamation of the epidermis may be 
noted upon the face and neck, upon the buttocks, and not infrequently upon 
the lower portions of the legs. 

Occasionally very marked peeling occurs, particularly in the face, which 
will then last for days, and may even assume a large lamellar character upon 
the temples and forehead. 

We now reach the deviations in the course and in the period of convales- 
cence. This is the true domain of the manifold local disturbances which the 
entire pathologic process suffers and which, often beginning insignificantly, in 
their further development reach a life-threatening severity, at other times, 
naturally, also, beginning abruptly in the course of a few days. 

Even where we do not discover the point at once at which the regular 
process of the reparative changes has been interrupted, there is always a 
symptom which may be looked upon as a signal of alarm and which under all 
circumstances should cause a careful investigation : This is an insufficient 
defervescence or the renewed rise of temperature in the period of convales- 
cence. It cannot be denied that occasionally a certain hesitating drop of the 
fever by lysis, or also a mild post-febrile course may occur without it being 
possible to determine a complication, but this is certainly not frequent and, as 
a rule, the previously mentioned variation of the body temperature may be 
looked upon as a sign of irregularity in the course of the disease which may 
cause anxiety for days and weeks. 



DEVIATIONS FROM THE NORMAL COURSE 645 

To present a well-ordered summing up regarding the manifold changes 
that may occur, it is necessary to present them in a topographico-anatomical 
review in which it is necessary to remember that often in the individual case 
quite a number of these secondary conditions may combine. 

In the eyes, the catarrh of the conjunctiva is often prolonged. Particu- 
larly in somewhat " scrofulous " children the mucous membrane inflammation 
which leads to the gradual agglutination of the lids may last for weeks and 
even for months; a stubborn blepharitis ciliaris is added, which, again, is 
followed by eczema in the surrounding tissues of the eye. Gradually there 
develop, in case treatment is not effectual, corneal phlyctenula and superficial 
ulceration, with photophobia, blepharospasm, in fact, the entire symptom- 
complex of " scrofulous " ophthalmia. 

Sometimes, however, the catarrh runs its course as a severe purulent con- 
junctivitis and marked painful edematous swelling of the lids, a true blennor- 
rhea of the mucous membrane of the eyes. I once saw the sad case of a boy 
who in the short period of a two-weeks attack of measles lost the sight of both 
eyes by a purulent pan-ophthalmia. The desperate father wanted to sue the 
physician who treated the child, before it was admitted to the hospital in 
Leipzig, for he believed — but quite unjustly — that neglect was the cause of the 
inflammation of the eyes. 

More manifold and numerous are the affections of the nasal mucous mem- 
branes. An infrequent but unpleasant, and, according to my experience, 
unfavorable, prognostic course, is shown by the ordinary coryza of measles, 
when dry swelling of the mucous membrane which may be referred to a more 
marked inflammation of the submucosa takes place. The children snuffle — it 
always occurs in earliest childhood — and when drinking or even otherwise 
when closing the mouth this becomes loud and prominent, the alae of the nose 
retract a little with every deep inspiration. Examination shows that there is 
no secretion in the nose, the opening is covered with dry brown crusts and 
partly closed. 

At other times there is a profuse purulent secretion from the nose, which 
often predominantly affects the nasal cavity, then this and its surroundings 
become excoriated, deep ulceration occurs, the adjacent skin often swells to a 
great extent and shows a hard and glistening upper surface. A smeary or 
lardaceous exudate is deposited upon the ulcers, ecthyma-like eruptions appear 
in the vicinity, which again ulcerate or are covered with thick crusts; a 
process which is accompanied by continued fever, markedly exhausting the 
affected individual, and while not in itself leading to a fatal outcome, never- 
theless causes prolonged invalidism. This condition may be designated as 
diphtheroid of the nasal mucous membranes and its surroundings. Frequently 
also the surroundings of the mouth take part in this ulcerative process and 
often complications, profuse diarrhea or pulmonary involvements, are added 
and may then lead to a lethal outcome. 

The distribution of the infectious mucous membrane affection from the 
nasal cavities of the posterior pharyngeal wall, and, above all, to the Eu- 



646 MEASLES, MORBILLI, RUBEOLA 

stachian tube, is still more important. It' the inflammatory process has once 
reached these tissues it rapidly distributes itself to the tympanic cavity and we 
then have the so very frequent complication of measles with otitis media to 
consider. 

This shows itself, almost always, by a new rise of the fever, often to a 
marked height, 10-1° F., and over, even above 105.8° F., the character, however, 
being remittent, so that usually in the morning remission occurs, the temper- 
ature falling to 102.2° F. or lower, even reaching the normal. The general 
condition again becomes worse, loss of appetite reappears and to this a certain 
unrest is added which is especially increased at night. Older children now 
usually complain of stitches or other pains in the ears, but by no means 
always, frequently there is a complaint of headache accompanied by hebetude 
and delirium at night. Small children usually moan continuously, but this 
is not always pronounced. Not rarely is the peculiar oblique position of 
the head seen in a unilateral otitis media, especially where, in connection 
with this, a painful lymph gland swelling develops under the sternocleido- 
mastoid of the same side. The ear speculum rapidly shows the cause of these 
symptoms. The tympanic membrane has lost its normal lustre, the light reflex 
has disappeared and, mostly, in the surroundings of the handle of the malle- 
olus, red or grayish-red swellings are noted. Xot rarely may a yellowish or 
yellowish-brown exudate be seen shining through the tympanic membrane. 
The pus which usually collects rapidly in the narrow space of the drum after 
a few days usually ruptures externally through the tympanic membrane. The 
point of perforation is most frequently situated in the posterior lower quad- 
rant. 

Where this spontaneous rupture does not occur, the catarrh of the tym- 
panic cavity with a moderately severe, more mucoid, inflammation may leave 
spontaneously, the fever disappearing by lysis. If, however, the fever reaches 
to its former height, then the artificial opening of the tympanic membrane 
must not be neglected, for, otherwise, further dangers threaten. The infec- 
tious inflammation attacks the antrum, insidiously implicates the cells of 
the mastoid process, and from here easily reaches the transverse sinus or 
the dura mater or pia mater. I have several times seen a septic sinus throm- 
bosis or subsequent pyemia due to an otitis media, which, a few weeks after 
the disappearance of the exanthem, terminated the life of the patient. 

Or the affection becomes a chronic otorrhea with carious degeneration of 
the bone, which, by causing suppuration in the brain much later, may result 
in death. This serious change in the otitis of measles may be prevented by 
timely interference. Painfulness, slight swelling, or redness of the mastoid 
process should always receive attention, and, even when these signs are absent, 
sometimes alone upon the basis of a fever that cannot be otherwise explained, 
a marked protrusion of the posterior wall of the external auditory meatus, or 
a very profuse suppuration, we must come to the conclusion to have the 
mastoid process of the temporal bone opened. 

The oral cavity may also be implicated in measles. Not very frequently 



DEVIATIONS FROM THE NORMAL COURSE 647 

there develops, especially, beside other complications, stomatitis of the mucous 
membrane of the palate, gums or cheeks. Mistakes may be caused if the 
mycosis appears in those areas in the period of convalescence of measles, in 
which in the prodromal stage the characteristic spots have been noted. This 
eruption is of little importance and is readily removed. 

Aphthous stomatitis occasionally gives rise to great difficulties. These 
painful eruptions may occur in all parts of the mucous membrane of the 
mouth, they occur particularly upon the gums of the incisor teeth and upon 
the adjacent inner surface of the lips, as well as upon the anterior part of the 
tongue, and often result in a very marked edematous swelling of the lips with 
formation of hemorrhagic fissures, also similar ulcers in their surroundings, 
as has been described under nasal diphtheroid. 

At other times more circumscribed but ulcerative inflammations occur in 
individual areas of the mouth and from them hemorrhagic infiltrations of the 
mucous membrane and mucosa are distributed along the gums. The sever- 
est form of this secondary mouth affection leads to noma which has a particu- 
larly close relation to measles. The description of this condition will follow 
later on. 

Finally, the larynx must be considered. That this organ in the first days 
of the disease may also give rise to symptoms of pseudo-croup has been men- 
tioned ; much more frequently, however, in the stage of convalescence there is a 
disturbing increase of the laryngeal catarrh. This usually occurs in young 
children from one to two years of age. 

Under continued and, occasionally, very high fever (over 104° F.) the 
hoarseness which was already present during the stage of eruption changes 
into complete aphonia so that even crying occurs quite without tone. Beside 
aphthous oral affections, also ulcerative nasal and lip affections of the variety 
described above may increase the difficulty. The children always become rest- 
less, do not sleep, throw themselves about, and it usually requires a few days 
until the stenosis of the larynx reaches a certain grade. Respiratory retrac- 
tions which are not very decided but are still worthy of note occur in the 
jugular space and in the epigastrium, especially if the child is irritated and 
as a consequence of this breathes rapidly. Then the inspirations and expira- 
tions are accompanied by those sounds which denote a beginning narrowing 
of the opening of the glottis. Inspection of the oral cavity shows reddening 
and soon also marked or slight swelling of the palatine and pharyngeal parts, 
but — in case aphthae are not present — no deposits or membrane formations can 
be noted. Now anxious hours and days begin. Prior to each visit the physician 
believes that the time for intubation or tracheotomy will have arrived, and yet 
no increase of the phenomena of stenosis can be determined. External palpa- 
tion of the larynx and of the trachea teaches that these parts are very sensitive 
to touch — therefore, by the superficial plugging of the cartilage, perichondrium 
and connective tissue they are in a condition of inflammatory infiltration. 
This clinical picture just described in fact depends upon an inflammation of 
the mucous membrane of the larynx and the surrounding parts (particularly 



648 MEASLES, MORBILLI, RUBEOLA 

the submucosa) , which is not infrequently confirmed by the autopsy. The 
changes which are found in the cadaver in cases of this kind are, a rigid, thick- 
ened epiglottis, prominent false vocal cords and arytenoid cartilage coverings, 
all showing a deep dark redness and being permeated by hemorrhages and 
showing a velvet-like swelling of the markedly reddened mucous membrane of 
the trachea from above downward to the bifurcation. It is, therefore, the 
severe inflammatory swelling of the supra- and subglottic covering of the 
membrane which causes this form of the disease that, clinically, may well be 
designated as laryngeal croup. It is also well in the treatment of cases of this 
kind to adhere to this conception for they are effectually influenced by a proper 
antiphlogistic therapy (blood letting). 

Croup occurring in measles, with membrane formation upon the vocal 
cords and upon the rest of the laryngeal mucous membrane, according to my 
observation, owes its origin to a diphtheritic infection, and for this reason will 
be considered later on. 

In older children the laryngeal affection does not readily assume such a 
threatening character as in the very young, for, in the first place, the phleg- 
monous inflammation does not readily lead to stenotic phenomena on account 
of the greater space of the glottis, and, secondly, the danger of the addition 
of distributed inflammatory foci in the lungs is a slighter one. Here, occa- 
sionally, the very marked tenacity of the hoarseness, which may lead to com- 
plete aphonia, and of the laryngeal cough, which may last for weeks and even 
for months, gives rise to fear. But, finally — at least in the cases that I have 
seen — complete restitution occurs. Anatomically the condition is due to a 
simple chronic catarrh without ulcer formation. 

It is now generally assumed, and I favor this view, that all of the enumer- 
ated complications and distributions of the catarrh, which were originally due 
to the toxin of measles, are no longer results of this but are due to the addition 
of new deleterious effects, and especially to the action of secondary bacterial 
infections. It does not appear that we are dealing so much with peculiar forms 
as with those generators of suppuration and inflammation which are found 
everywhere and particularly in the nasal and oral cavities of both the healthy 
and the sick : staphylococci, streptococci, pneumococci, coli varieties and the 
like. The possibility of their successful onslaught is prepared by the attack of 
measles and perhaps particularly increased by external physical deleterious 
influences ( refrigeration ) . 

The same is true also of the numerous and especially important affections 
on the part of the bronchi and lungs, which appear unexpectedly in the period 
of convalescence. Often, however, these disturbances have already begun 
during the acme of the eruption and increase later; nevertheless, it 
frequently happens that nothing points to the complication which develops 
later on. 

The most dangerous form under which the pulmonary complication appears 
is the catarrhal inflammation of the smallest bronchi, which rapidly distrib- 
utes itself over the entire bronchial tree, acute capillary bronchitis (bronchi- 



DEVIATIONS FROM THE NORMAL COURSE 649 

olitis, suffocative catarrh). It attacks particularly weak children in the first 
and second years of life, but it by no means spares older children. Thus I once 
saw a boy aged seven years, for over a week after measles had disappeared show 
a dyspnea with 80 respirations per minute, being in an exceedingly dangerous 
condition. 

The prodromes are usually without alarming phenomena, often being 
accompanied with but slight symptoms; the eruption has usually become pale 
but has appeared over the entire body and then shows a confluent character 
over the trunk — then the general condition of the child changes. He becomes 
conspicuously pale, while the remains of the exanthem take on a livid color, 
the child being restless and very dyspneic; the pale semitransparent alae of 
the nose move regularly, the diaphragm heaves, drawing the lower portions 
of the thorax inward, and the auxiliary muscles of respiration enter into 
action. The fever does not run very high, hovering about 102.2° F., the pulse, 
however, shows an unproportional high frequency, rising to 160, 180, even 
200 per minute. An examination of the lungs at the onset shows but little 
regarding the severity of these serious symptoms of disease, but from day to 
day numerous fine rales are heard, first in the lower posterior parts of the 
lungs, soon rising higher and higher, and then also being heard in the lateral 
aspect of the thorax. Tracheal rales are heard at a distance, the cough which 
becomes feebler and feebler is no longer sufficient to bring up the contents of 
the bronchial tubes. The unrest and anxiety give way to semiunconsciousness, 
and the patient lies with half-closed eyes, the bulbae being turned upward; 
occasionally general convulsions occur, the pulse becomes smaller and smaller, 
and gradually life ceases after but a few days of this condition. At the autopsy 
no changes, or but slight ones, are found in the lungs, but the smaller and 
finest bronchi are filled by a tough muco-purulent secretion from the inflamed 
mucous membranes. Two-thirds to three-quarters of the bronchial tree may 
show this condition; the anterior upper parts are most resistant and remain 
permeable to air. 

The course is less rapid if the inflammatory mucous membrane affection 
does not disseminate itself rapidly over the greatest portion of the bronchi 
but limits itself to one or the other pulmonary lobes. Then, primarily, a 
circumscribed capillary bronchitis arises, which, with a somewhat prolonged 
duration, is always connected with the sequelae of catarrhal pneumonia in one 
area, atelectasis in a second, and alveolar dilatation of a third point. At 
the necropsy a high grade hyperemia of the vessels in the pulmonary area 
may be determined, from which it is concluded that during life a large part 
of the amount of blood has accumulated here and has become unsuitable 
for the function of internal respiration, besides having caused increased. labor 
in the mechanism of the circulation. Finally, the rapidly appearing cellu- 
lar infiltration of the pulmonary tissue in the surroundings of the diseased 
bronchi reaches such an extent that the inflammatory irritation has not only 
affected the surface of the mucous membrane but has permeated into the 
depths of the same. 



650 MEASLES, MORBILLI, RUBEOLA 

The clinical picture is somewhat less fulminant than in the former 
instance; it is true, fever, increased rapidity of the pulse and dyspnea show 
the nature and the seat of the affection which has followed measles, but the 
fever, although it may show exacerbations, is markedly remittent and even 
intermittent, and the other symptoms are of a more moderate grade. Phys- 
ical examination usually reveals the principal pulmonary portion affected; 
profuse loud, coarse, and fine rales are noted usually in the dependent por- 
tions of the lower lobes, to which there is rapidly added a diminution of the 
resonance on percussion, with the appearance of broncho-vesicular breathing 
or even pure bronchial breathing, which completes the diagnosis of the impli- 
cation of a more or less large pulmonary division. The general condition 
is commonly greatly disturbed, lassitude, irritability, anorexia and insomnia 
being accompaniments of the local condition. A distressing cough helps to 
diminish the powers of the little patient, and the condition is made worse by 
inflammations of the mouth, severe laryngitis or by intense intestinal catarrh. 
However, this form of morbilli pneumonia after a series of several days often 
enough terminates in recovery. 

The favorable outcome is less frequent in those cases in which the severity 
of the infection rapidly shows a distribution of the inflammation over an 
entire lobe of the lung or frequently over two or more lobes. This may 
usually be recognized in a very brief time as the physical signs develop very 
rapidly in this condition. In such instances, similar to lobar fibrinous pneu- 
monia, there is marked dulness upon one or both sides which may also take 
in the lateral aspect of the thorax, sometimes also showing lobar catarrhal 
infiltrations of an upper lobe; with this there is marked bronchial respiration 
in the area of dulness, besides which, however, many rales may be heard at 
various areas. The fever has a more continued character and is high, but 
it may also assume another form. The pulse is very frequent, the respiration 
sighing and it appears to be painful, also upon palpation and in percussion 
of the affected parts the patients complain of pain. Exhaustion occurs more 
rapidty than in the previously described variety; the tongue becomes dry. 
The lips show sordes; frequently galloping respiration accompanied by sigh- 
ing; in older children there is prolonged delirium, in younger children con- 
vulsions occur. Anorexia is complete, but severe thirst compels the children 
to consume the fluid nourishment which is given them. The urine is scant 
and concentrated. In spite of the severity of these phenomena, even this 
lobar form of post-measles pneumonia is endured longer than the first 
described capillary bronchitis; strong children may even finally recover from 
the condition. It is worthy of note that after defervescence the absorption 
of the exudate in a pulmonary lobe which has been infiltrated in this man- 
ner may require weeks and even months before complete recovery finally 
takes place. 

But, unfortunately, as may be only too frequently demonstrated by autopsy, 
it is seen that in fact the condition is due to a lobar pneumonia, of two 
or even three lobes, in which, however, the original nature is shown by 



DEVIATIONS FROM THE NORMAL COURSE 651 

the lobular appearance of the section; besides, the character of the exudation 
is not infrequently of a mixed nature: fibrinous, hemorrhagico-fibrinous and 
catarrhal exudations are found side by side and intermingled. The pleura 
in these cases is always found implicated; thin, fibrino-purulent deposits, and 
inflammatory cloudiness are found in wide areas; beneath the deposit the 
pleural tissue is permeated by numerous round hemorrhages from the size of 
a pin-head to that of a lentil. 

Exceptionally large, purulent, or sero-fibrinous, or even hemorrhagic exu- 
dates develop. 

The digestive organs do not remain free from secondary infection, although 
this is much rarer. It has already been mentioned that in all intense infec- 
tions in measles the mucous membrane of the smaM and large intestines, and 
especially their lymphatic apparatus, are always implicated. Besides the pre- 
viously described inflammations of the mouth, the larynx, the bronchi and the 
lungs, there are invariably found in the cadaver more or less well-developed 
signs of an implication of the intestinal tract. 

Occasionally the digestive tract is attacked alone, whereas the respiratory 
organs are spared. In some cases, not alone in nurslings but in older children, 
the entire affection begins, in addition to the usual catarrhal phenomena, or 
even instead of these, with severe vomiting and watery discharges which occur 
frequently, five or six times daily. In the further course of the affection 
vomiting ceases but the diarrhea continues during the entire course of the 
disease and only desists with the disappearance of the exanthem. This diar- 
rhea does not appear to have a particularly unfavorable influence upon the 
course of the affection. In the case of a child aged two years a severe pneu- 
monia was added, and while from the paralyzed anus the thin yellowish-white 
contents of the intestinal tract flowed continuously, the child succumbed to 
the pulmonary inflammation. 

More frequently diarrhea occurs during the time of critical defervescence, 
which may almost be looked upon as a critical discharge. Without markedly 
influencing the general condition during the time of the disappearance of the 
exanthem, there are muco-hemorrhagic or muco-purulent stools, being small 
in amount but occurring in rapid succession. The condition, however, is of 
brief duration, a day to a day and a half, then it disappears, often with- 
out treatment. At other times, during the period of convalescence, a few 
days after the disappearance of the eruption, with the addition of fever, 
severe abdominal pains, and general illness, a marked diarrhea sets in, with 
thin, foaming, profuse, at other times sparse, frequent mucous discharges. 
With suitable diet and treatment this condition is controlled, but usually 
somewhat prolongs convalescence. 

But this is not always the case. Instances occur in which the intestinal 
affection shows great severity, there is marked tympanites and painfulness of 
the abdomen ; with this there is high fever, severe implication of the senso- 
rium, a dry tongue, briefly, a condition which markedly resembles the typhoid 



652 MEASLES, MORBILLI, RUBEOLA 

state. In a case of this kind, in my clinic, I found at the autopsy a severe 
enteritis with septic processes. 

This diarrhea is always unpleasant and of questionable prognosis if it 
occurs in connection with any severe complication, especially if it implicate 
the lungs. It requires particular attention, and in young children readily 
leads to a life-threatening exhaustion provided we do not succeed in rapidly 
removing the condition. 

Finally, the intestinal affection may assume the character of a true dysen- 
tery, in a clinical as well as in a pathologico-anatomical respect. It is, how- 
ever, not unlikely that affections of this kind are not due to the usual but to 
the specific pathogenic agent. In the year 1892, a child simultaneously suf- 
fering from measles and a severe dysentery, was admitted from a children's 
asylum to the Leipzig Hospital, to the division for measles. In a brief period 
this affection was transmitted to six other patients, and of the seven children 
attacked in this manner, five died. The autopsy showed the same changes, 
a severe hemorrhagic inflammation with a distributed coagulation necrosis 
of the entire mucous membrane of the large intestine (diphtheria in an 
anatomical sense), that I saw during the Franco-Prussian War in soldiers 
suffering from dysentery during the sieges of Metz and Paris. 

Threatening symptoms rarely occur on the part of the nervous system. 
A moderate grade of implication of the sensorium and of delirium during the 
mildly febrile exanthematic stage belong to the clinical picture of measles. 
In nervous children these deliria sometimes occur upon the first day of the 
initial fever and accompany the period of eruption even if the temperature 
does not rise very high. In a child aged three years I saw a delirium appear 
with an evening temperature of 102.7° F. 

Severe stupor, a soporous condition, or wild delirium are found more 
frequently in adults than in children during the acme of the eruption. 

Barely these severe toxic symptoms also occur in children. 

In quite a fat girl aged seven years, who had a very intense eruption, I noted two 
days of complete confusion with severe delirium following the day of the acme of the 
disease. The girl rose in bed, endeavored to run from the room, cried and fought, had 
delusions of fear with slight hallucinations which resembled alcoholic delirium, saw a 
number of maggots moving about upon the ceiling and the like. Gradually she became 
quieter and, finally, after a brief period she recovered completely. 

The delirium occurring during convalescence is more remarkable, re- 
sembling the post-pneumonic disturbances of adults. 

In a boy aged six years, at the end of the eruptive stage, in the morning after a 
fall of temperature (from 104.4° F. to 99.9° F. ), there occurred a delirium with hallu- 
cinations. He thought that he heard drums and ran to the window to see the soldiers, 
then from all four corners of the room storks appeared which bit him in the leg; he 
began to rave and curse, and pulled the hair of his father, who was holding him. This 
condition lasted the entire day up to five o'clock in the evening. After the use of 



DEVIATIONS FROM THE NORMAL COURSE 653 

chloral quiet appeared. During the next days signs of hallucination with mild fever 
recurred and then the complete normal condition returned. 

A more serious symptom is the occurrence of convulsions in the course of 
measles. In the stage of invasion they are rare and, according to Trousseau's 
experience, are not of unfavorable prognosis. Where, on the other hand, 
they occur at the time that the eruption should appear, which almost exclu- 
sively happens in children from one to two years of age, they are very serious 
and indicate a very severe general intoxication which almost invariably results 
in death. I have occasionally seen this in the stage following the eruption, 
in the second week of the entire affection, as an accompanying symptom of 
pulmonary or bronchial affection — but not with the same unfavorable prog- 
nosis. Often the cases terminated in recovery. 

It will always be well to give a guarded prognosis even in these post- 
morbilli convulsions, in view of the experience that measles belongs to those 
infectious diseases in which encephalitic conditions may arise, for, prior to 
leading to paralyses, they show themselves first in the form of convulsions. 

The skin is not infrequently implicated in the measles process, apart from 
the described variations of the eruption. Once, in a child aged two years, I 
saw convalescence retarded by a very intense eruption of miliaria. Occasion- 
ally, in children who have been weakened by diarrhea or chronic pneumonic 
affection, stubborn furunculosis arises, also eruptions resembling pemphigus 
may appear even a long time after the disappearance of the measles exanthem. 

In septic endocarditis, hemorrhagico-necrotic foci of a circumference of 
several centimetres appear upon the abdominal wall or also upon other parts 
of the surface of the body. 

The severest cutaneous affection, upon the whole very rarely occurring in 
a large number of cases in individual epidemics, is noma, cancrum oris. Its 
point of selection is the skin of the cheek and the surroundings of the female 
genitalia, the large labia and neighboring parts. I once saw it arise from 
the floor of the mouth beneath the tongue, in a tuberculous child suffering 
from measles and whooping cough. The point of entrance for the pathogenic 
agent of this gangrenous condition, which advances with dreadful rapidity, 
always appears to be an ulcerated area in the mucous membrane, either in 
that of the cheek near the angle of the mouth, or in the vulva. The poison 
rapidly passes through the tissues; soon an elastic edema is noted in the 
affected area of the face opposite the mucous membrane of the cheek, in which 
first there is a brownish then a blackish area, indicating complete necrosis 
of the affected portion of the cheek. While this decomposes to a slimy gray 
green, dreadfully offensive mass, the gangrene advances into the depths of the 
tissues and into the surrounding areas, usually in a manner quite painless 
to the child, but with increasing, finally fatal, exhaustion. For the most part 
the affection occurs in children that are otherwise cachectic. Regarding the 
claim lately made connecting the affection with the pathogenic agent of diph- 
theria, further investigations are necessary. 



654 MEASLES, MORBILLI, RUBEOLA 

Occasionally rheumatic, arthritic and cardiac affections occur in connec- 
tion with measles, but much more rarely than in the case of scarlatina. 

In a somewhat debilitated boy aged eight years, five days after the appearance of the 
eruption, I saw renewed fever, and two days later both hip joints were attacked with 
extraordinarily severe pains. Even lifting the bedclothes led to a scene of crying, and 
an accurate examination of the markedly retracted legs was impossible. We considered 
it a severe purulent arthritic inflammation. Simultaneously, a soft systolic murmur 
could be heard in the heart; in the course of four days both anomalies disappeared 
completely under the use of sodium salicylate. 

However, even without inflammation of the joints, in the period of con- 
valescence, benign endocarditis occurs, from which recovery takes place, but 
under some circumstances it may even lead to permanent valvular disease. 
Malignant endocarditis is found in individual cases after an especially severe 
case of necrotic measles pneumonia. 

The kidney is but very rarely damaged ; at the height of the severe febrile 
exanthematic stage toxic albuminuria is noted, which, however, rapidly dis- 
appears; in the post-eruptive stage the kidney is spared. 

In those rare cases in which an infectious nephritis accompanies measles 
the conditions are the same as in hemorrhagic desquamative scarlatinal nephri- 
tis, and, similarly, may remain as a chronic affection. 

COMBINATIONS OF MEASLES WITH OTHER SPECIFIC ACUTE OR 
CHRONIC INFECTIOUS DISEASES 

Measles may be combined with other acute exanthemata, in that they may 
either precede or follow the condition, or also that they may run their course 
simultaneously in the same person. I have seen the latter condition in the 
case of varicella, vaccinia and scarlatina. In such cases we have the impres- 
sion that both infections run their course in the same organism without 
particularly influencing one another. At most, one or the other may show 
a briefer course than usual. For example: 

A boy aged six years was taken ill upon November 20th, with cough and coryza. 
Remained in bed. Upon November 23d, complained of headache, difficulty in deglutition 
and hoarseness. Evening temperature upon November 25th, 102° F. ; upon November 
26th, in the morning 101.5° F., evening 103.4° F. ; pains in the eyes. Right tonsil 
swollen and reddened, pharyngeal catarrh. November 27th, eruption of varicella; morn- 
ing temperature 101.8° F., evening temperature 103.4° F. November 28th, varicella 
eruption disappearing. First eruption of measles in the face; temperature 102.9° F., 
in the evening 104.2° F. November 29th, maximum temperature 103.6° F., evening 
temperature 103.4° F. November 30th, temperature 103.1° F., evening 100.8° F. De- 
cember 1st, temperature 99.1° F., eruption of measles disappeared. 

Similar conditions may occur in vaccinia. 

A girl aged four, who for two years had suffered from infantile cerebral paralysis, 
upon May 27th was vaccinated while she was in the stage of incubation of measles. 



COMBINATIONS OF MEASLES WITH OTHER DISEASES 655 

June 3d, coryza and cough. June 5th, eruption of measles appeared and developed to 
its maximum to June 7th; temperature 104.7° F., evening 104.4° F. ; June 8th, 102.9° 
F., evening 100.9° F. The vaccine pustules began to dry. June 9th, 103.4° F., evening 
101.1° F., eruption becoming pale. June 10th, 100.8° F., evening 100.2° F. June 11th, 
101.8° F., evening 99.9° F. Afebrile thence on. No reason could be found for the " after 
fever " of measles. It might be referred to vaccinia. 

At other times measles disturbs the course of vaccinia, provided the affec- 
tion occurs soon after vaccination, the measles process itself not remaining 
uninfluenced, as, for example, in the following case: 

Boy aged fifteen months, vaccinated upon July 2d. Upon July 3d, conjunctivitis and 
cough. The eruption of vaccinia does not develop properly. Only upon July 9th does 
the eruption of measles show itself, to disappear upon July 14th; during the entire 
eruptive period, fever (up to 103.5° F.) and marked dyspnea are present. 

Upon July 10th, the eruption of vaccinia appears as it would in other cases upon 
the fourth or fifth day; upon July 12th, the areola appears, the pustules being well 
developed upon July 14th. On July 15th desiccation occurs. Continued fever which is 
prolonged to July 24th by a suppurative otitis media. 

To diagnosticate the simultaneous course of measles and scarlatina is 
always very difficult, still I believe I have observed cases of this kind, the 
double character of which could be discerned by the symptoms and the subse- 
quent sequels. I have certainly observed the appearance of both exanthems 
at the same time in the same family. A girl aged one year showed a normal 
attack of measles (catarrhal symptoms being present during the stage of 
incubation) without being affected by scarlatina before or afterward, whereas 
two older children suffered from scarlatina. 

If the exanthems succeed each other, the course of the affection depends 
in the main upon whether the severer infection or the milder one follows. 
In the former case the prognosis is always uncertain. Measles following 
varicella more readily takes an unfavorable course and shows complications 
than vice versa. Naturally, if varicella occurs during an irregular attack of 
measles this is capable of aggravating and of prolonging an existing bron- 
chitis or pneumonia. 

Of 10 cases of measles in my clinic, occurring in connection with scarla- 
tina, 1 died. Of 10 cases of scarlatina following measles, 4 died. 

Measles may combine with other acute cutaneous eruptions. Twice in the 
same epidemic I saw a very intense erythema exsudativum multiforme appear 
in the stage of convalescence of measles; once eight days after, the second 
time twenty days after the maximum of measles had been reached, in both 
cases lasting several weeks. Herpes zoster, etc., also occurred. 

According to my experience, one of the most serious combinations is that 
of measles with dipli th eria. I cannot escape the impression that the organism 
attacked by measles offers less resistance to the intoxication and infection 
from diphtheria. The aid which a specific treatment usually furnishes in 
so excellent a manner in overcoming diphtheria is of less value in the case 
of patients suffering from measles and diphtheria. Even passive immuniza- 



656 MEASLES, MORBILLI, RUBEOLA 

tion gives protection but for a very short time. As soon as diphtheria occurs 
in connection with measles it shows a tendency to wide distribution, to a 
rapid implication of the larynx, quickly descending into the bronchi. 

Wherever I have had an opportunity for a bacteriological examination, 
all cases of so-called morbilli-croup, in which there is an active formation of 
membranes, have shown, by the presence of diphtheria bacilli, that they were 
of a diphtheritic nature. In no other case have I seen the propagation of a 
diphtheria exudate from the tonsils to the bronchi in all its divisions, into 
all lobes of the lungs, in the course of twenty-four hours, except in a girl 
aged four years, who upon the day of the maximum in the eruption of measles 
showed the first coating upon the uvula and upon the next afternoon suc- 
cumbed, showing a temperature of 107.6° F. Her elder sister who had pre- 
viously had an attack of measles and at the same time was suffering from a 
severe attack of diphtheria recovered. 

The course of diphtheria in measles is then particularly fulminant and 
markedly febrile when it occurs at the acme of the period of eruption or 
just prior to this. If the second infection occurs during a later period in 
measles it may resemble the course of the usual forms of the disease. Very 
frequently, in these cases the palate and pharynx remain free from membrane 
formation, the infection from the onset at once attacking the larynx. 

But even then, when measles follows diphtheria with an almost simul- 
taneous infection, both diseases may influence each other in a very ominous 
manner. 

A strong boy aged seven years, in good circumstances, taken ill upon February 18th, 
from diphtheria, which rapidly assumed large dimensions in the pharynx. On February 
20th he received 600 antitoxin units, and on February 21st, after I had visited him 
for the first time, he at once received 1,500 more. On February 23d he had attacks 
of fear, without actual symptoms of stenosis, due to marked swelling and formation 
of membrane in the pharyngeal parts. Moderate albuminuria, then improvement. Upon 
February 27th, renewed fever. Upon March 2d an eruption of measles appeared, at 
once severe apathy and high graded asthenia occurred; gallop rhythm. During the 
night from March 4th to 5th embolism of the left crural artery; absence of pulse up 
to the inguinal region, severe pain. During the night, from March 8th to 9th, death 
occurred. In this case the periods of infection with the contagium of measles and 
diphtheria were close together. 

Another very undesirable combination is that of measles and whooping 
cough. As both affections implicate the same mucous membrane areas their 
influences increase the difficulties and lead to the great danger of severe 
complications on the part of the lungs and bronchi. It also appears to be 
the rule here that the combination shows more unfavorable prospects in cases 
in which the more intense infection — and measles may be properly looked 
upon as the more severe — is added to the milder, than if whooping cough 
occurs in connection with measles. 

In the former case, particularly in children in the first years of life, an 
incomplete development of the cutaneous eruption is apt to occur or the 
eruption is retarded, going hand in hand with a fulminant development of 



COMBINATIONS OF MEASLES WITH OTHER DISEASES 657 

a very extended bronchiolitis which rapidly leads to death. In the second 
instance another danger is present, the catarrhal inflammation of the bronchi 
and lungs, which is due to the measles process, or which has only developed 
in connection with the appearance of whooping cough, readily takes a Sub- 
acute or chronic character, thus prolonging the total affection for weeks or 
even for months. Then chronic indurative processes, particularly of the lower 
lobes, with the formation of c}dindrical bronchiectases occur, and then, as 
well in connection with the local phenomena as with the general condition, 
with the continued fever and the high graded emaciation, the affection may 
very closely resemble tuberculous phthisis. 

Finally, the connection of tuberculous infection with the measles process 
must be considered. The influence of this acute infection upon tuberculosis 
is most clearly recognized in those cases in which it attacks the child that 
suffers from a latent or quiescent tuberculosis of the bronchial glands. Here 
it awakens to new life — naturally, up to this time in a manner by no means 
clear — the quiescent germs of the chronic infectious disease. By way of the 
lymph channels, or from a caseous area of the capsule of the gland, they 
reach the surrounding areas, and here give rise to a local miliary tuberculosis, 
which, if the lethal termination occur soon after the onset of measles, brought 
about by other complications, may be found in the earlier stages or also, upon 
a rupture into a bronchus, may show recent tuberculous pneumonia. 

An example of such connection is furnished by the following case: 

Arthur Gr. began to cough at the age of eleven months. Then he had an attack 
of varicella. In the second half of the twelfth month the cough was aggravated. In 
January, 1880, a child aged one year, which was very pale and miserable, with a profuse 
rattling cough, and high irregular fever, but without signs of an implication of the 
finer bronchi was seen. This condition continued for nearly a month, then the cough 
disappeared, but later frequently returned. Strength and weight, however, increased 
in a satisfactory manner. At the beginning of June he was attacked by measles. On 
June 3d the eruption appeared, a disseminated bronchitis was added, and upon June 8th 
the child was found dead in bed. Autopsy. Child still well nourished. In the lower 
lobes both lungs show short and firm pleuritic adhesions. Left upper and right lower 
lobe show flaccid infiltrations, beneath which there is a large caseous focus about 1 c.c. 
in diameter. Eight middle lobe shows flaccid infiltration, partly atelectatic. A very 
large gland at the bifurcation of the trachea shows complete caseation, one half of 
which is softened. Quite recent development of tubercles in the spleen and in the liver. 
Mesenteric glands swollen but nowhere caseous. 

In another series of cases the first symptoms of a " scrofulous " mucous 
membrane inflammation occur directly in connection with measles, for exam- 
ple, stubborn conjunctivitis palpebrarum, then phlyctena and ulceration of 
the cornea, with severe eczema about the eyes, the face and the head appear. 
Now the cervical lymphatics enlarge, cold abscesses develop, and a few weeks 
later suddenly the neck is seen to swell, and a tumor alius develops. Again, 
a few months later an individual attacked in this manner may develop a tuber- 
culous meningitis and succumb. Here the condition appears to be reversed; 
measles has attacked a previously healthy child, and only on account of the 
43 



G58 MEASLES, MORBILLI, RUBEOLA 

acute infection does the individual become favorably influenced for the 
entrance of the tubercle bacillus; in the exantheni described, the germ may 
enter injured areas of the skin or the mucous membrane of the nose or eyes. 
Much more doubtful, and as yet not determined by accurate observation, is 
the direct infection of the lungs and the bronchial glands by tuberculosis 
during an attack of measles. The fact must be looked upon with certainty, 
that not rarely children as well as adults that have been entirely well previous 
to an infection by measles, show the first signs of a beginning pulmonary 
affection after the disease has run its course. Among the acute infections, 
particularly measles with whooping cough takes the first place. 

Perhaps the following case of previously diseased lungs, as during an 
attack of measles, may be looked upon as an immediate tubercular infection. 

A child aged two years, that from the end of its first year of life frequently suffered 
from bronchitis, is admitted to the clinic with the symptoms of a fibroid chronic pneu- 
monia of the left lower lobe. After the onset of phenomena of marked dulness, which 
remain about the same, so that empyema is constantly suspected, an aspiration proves 
negative; some time later, the symptoms of cavity formation occur in the affected lobe. 
Dozens of times the expectoration is examined for tubercle bacilli with negative 
results. The improvement in the general condition and the increase in weight are 
opposed to the diagnosis of tuberculosis, therefore, a diagnosis of atrophy of the lung 
with bronchiectasis is made. When three years of age, upon November 28th, the child 
had an attack of measles. Readmitted to the clinic upon December 12th, fever returned 
and emaciation was rapid. Now, to our surprise, the examination of the expectoration 
showed numerous tubercle bacilli. At the autopsy it was shown that a high-graded 
bronchiectatic condition, with secondary atrophy of the left lung, was present, because 
in the markedly swollen bronchial glands, as well as in the healthy lung, a moderate 
amount of fresh young tubercle nodules were found disseminated. In the preparation 
which was examined by Virchow a caseous focus could not be discovered. 

The possibility of a special liability of the eruptive and convalescent 
stages of measles (perhaps even of the prior stage) to a tuberculous infection 
gives a very important direction to practical treatment. The little patients, 
particularly at this time, must be guarded, with special care, against contact 
with tuberculous patients. 

DIAGNOSIS 

The detection of measles during the time of the eruption is easy in 
general for the physician who has seen a number of cases. The art of recog- 
nizing cutaneous eruptions rapidly and correctly cannot be taught by books, 
no detailed description, no matter how skilfully the words are chosen, not 
even the reproduction by means of pictures, but exclusively and alone can this 
be taught by clinical experience. This is also true of measles. The config- 
uration of the individual points in the eruption, their influence upon the sur- 
rounding areas, the distribution over the body are, however, so characteristic 
that even in the examination of a few cases the well developed eruption may 
be recognized by the beginner, even by the layman. Nevertheless, marked 
diagnostic difficulties even occur to the most experienced ; perhaps more rarely 



DIAGNOSIS 659 

in the case of the child than in the adult. Here in some cases the individual 
macule of measles, particularly in the first appearance on the face, is so 
markedly infiltrated that a number of distinct but very close nodules upon the 
forehead, eyelids, cheeks, nose and the surroundings of the mouth, which are 
intensely red and have a glistening appearance, give such an impression that 
the experienced observer is more likely to consider a beginning smallpox than 
an attack of measles. Even to-day there remains in my memory the horror 
of a very sensitive, nervous musician who, during the time of an epidemic of 
smallpox, was admitted late at night to the Leipzig Hospital, and placed in 
the smallpox division, but whom I was able to free from his unpleasant sur- 
roundings on the next morning, fortunately without having acquired smallpox 
in addition to his measles. At another time I observed in a student who had 
15 to 20 large bright nodules distributed over his entire body, exactly like a 
beginning varioloid, the eruption being surrounded by a red areola, that only 
upon the succeeding day was the first appearance of a very well developed 
eruption of measles noted in the surrounding of the nodules. 

A second difficulty is occasionally due to the differentiation from scarla- 
tina. Sometimes measles — but quite rarely — may retain its original small 
macular character without the larger serrated figures appearing, the entire 
eruption then resembling scarlatina. If then, accidentally, in place of the 
usual catarrh, the pharynx particularly is intensely red or even a lacunar 
tonsillitis appears, the differential diagnosis may be exceedingly difficult, a 
condition which I have seen. Then it is always important that the sur- 
roundings of the mouth and chin show the same features as the rest of the 
eruption, these parts remaining free in scarlatina, whereas in measles they 
are always implicated. 

The entirely confluent measles, in which the trunk, upper arm and thigh 
show themselves as covered by a continuous intense redness, may also confuse 
a less experienced observer, but the expert will note that in some few com- 
pletely normal areas, white points in the skin are present in the midst of 
these red surfaces, this being the appearance in measles, and that if upon 
pressure over the red areas the small deep reddened points do not return first, 
that scarlatina is not present. The differentiation may become very difficult 
in the case of rudimentary exanthems, that occur only upon the arms and 
legs, conditions that happen in both diseases. The exact determination of 
the accompanying phenomena, particularly those relating to the mucous mem- 
branes, must then clear up the situation. 

Eotheln in general is of a much lighter color than measles, although the 
appearance of the individual macules is often very similar, besides fever is 
usually absent in rubella. 

Great similarity is shown by the individual cases of serum exanthem, 
such as we meet with not infrequently in the specific treatment of diphtheria. 
The previous affection and the absence of the characteristic catarrh lead to 
the recognition of the proper affection. 

The exanthems occurring in the course of other infectious diseases may 



660 MEASLES, MORBILLI, RUBEOLA 

resemble measles, for instance in the case of epidemic cerebrospinal menin- 
gitis. Quite frequently the " septic " cutaneous eruptions which occur in 
severe intestinal affections of nurslings show a similarity to measles and may 
very readily lead to mistakes in diagnosis. 

Further, urticaria belongs to the affections which may resemble measles. 

Finalty, drug eruptions must be considered, for example, those occurring 
after antipyrin and analogous drugs, producing morbilloid eruptions, but care 
must be exercised not to carry this finesse too far. In the instance of a 
case of whooping cough, in which the child was treated with quinin, a very 
experienced colleague could not be convinced that an eruption which had 
appeared was due to measles. As, however, some time later the brother of 
the patient was attacked with the same eruption, the physician had to admit 
his error, but the family lost entire confidence in him. 

All the previously mentioned difficulties play an important role in the 
case of the individual physician who makes an error, and such mistakes are 
invariably remembered. But, in general, they are rare and seldom lead to 
mistakes in treatment, for the careful physician will always delay making 
a positive decision and will always, under all circumstances, treat the case as 
an infectious disease. 

It is unfortunate that the diagnosis of measles is so uncertain before the 
appearance of an eruption and prior to the incubation, as well as during the 
first day of the disease ; for during this time the patient is already a menace 
to those about him, perhaps to the same extent as at the height of the disease, 
as most contagions occur particularly during the period of invasion, which 
circumstance we should like to avoid. The appearance of a catarrh, with 
pains in the eyes and lachrymation, especially in a season in which measles 
is epidemic, should always be suspicious. The only characteristic symptoms 
of the prodromal period are the fine spots upon the mucous membranes of 
the cheeks (Koplik's symptom). In many cases, however, they are not present 
upon the first day, or are so feebly developed that they are of no value in 
diagnosis; but upon the second day of the disease they are usually present. 
In a suspicious coryza we should not omit, at least where we desire to pro- 
tect other children, to carefully examine the mucous membrane of the cheek. 
The delicate eruption can only be seen with great difficulty by gaslight. It 
is best seen by diffuse daylight or in sunlight. 

According to my experience, these spots do not occur in cutaneous erup- 
tions resembling measles, particularly in rotheln; they are, therefore, a valu- 
able diagnostic aid for the diagnosis of the stage of invasion. 

PROGNOSIS 

Measles represents a comparatively mild, febrile disease, at least regard- 
ing the immediate mortality. Hospital experience is capable of showing but 
insufficient conclusions, as hospitals for contagious diseases as well as chil- 
dren's hospitals in the main admit only severe cases, many of these coming 



PROGNOSIS 661 

in after the eruptive stage, and particularly because the division for measles 
in hospitals constantly shows numerous cases of secondary measles, this always 
unfavorably influencing the mortality. A much clearer picture regarding 
general prognosis may be gathered from the experiences of district physicians, 
those practising in a limited population. Jiirgensen, 1 in Tubingen, in 868 
cases in twenty years, has observed a mortality of 6.1 per cent. ; Fiirbringer, 2 
in Jena, in one epidemic, only found a mortality of 8.1 per cent. In the 
district in Leipzig in which I practised for fifteen years, in nearly 600 cases 
(594) I had a total mortality of 6.5 per cent., therefore, the same mortality 
as in Tubingen. If it is considered that this character of the disease in the 
course of two decades has made itself felt in the poor population living 
under the most unfavorable unhygienic conditions in a large city, it must 
be admitted that measles is comparatively a benign affection. In hardly any 
other disease (with the exception of whooping cough) is the course so much 
affected by the external manner of living of the patient as in measles. In 
this connection my own statistics are particularly instructive because they 
may be divided into two periods. 

In the first period up till 1884, those portions of the city which com- 
posed my district consisted of alleys and cellars and the population was 
almost exclusively assisted by charity. At that time the mortality was 10.3 
per cent. (278 patients). In 1885 the population changed, new streets were 
broken through, many of the poorest dwellings disappeared and the patients 
for the most part consisted of better situated workmen and the like. The 
mortality in the six years of the second period was only 3.1 per cent (316 
patients). In the individual epidemic Jiirgensen's mortality varied between 
3.7 per cent, and 8.9 per cent.; with me in individual years between per 
cent, (very small number of cases) and 15 per cent. In private practice 
among the well-to-do the proportion is decidedly more favorable (according 
to Fiirbringer twice as good). 

In the individual case the prognosis depends greatly upon the constitu- 
tion. Secondary measles is particularly serious; constitutions which have suf- 
fered on account of malnutrition, bad housing and insufficient care, young 
children suffering from anemia, severe forms of nephritis, scrofula, etc., 
always have decidedly poorer chances of withstanding the disease. 

Eegarding the individual phases of the disease no certain prognostic con- 
clusion can be drawn from the stage of invasion. During the period of erup- 
tion a poor development or a retarded state of the exanthem is of unfavorable 
prognosis as well as the appearance of convulsions; the usual severe cerebral 
symptoms, somnolence, delirium, etc., are not necessarily unfavorable. In the 
stage of convalescence any continued or returning rise of temperature after 
the eruption has disappeared denotes an irregularity in the morbid process. 



i " Handbueh der speciellen Pathologie und Therapie," von Nothnagel, Band iv, 
Thiel 3, Abtheilung 1 : " Acute Exantheme," 1895. 

2 Eulenburg's " Real-Encyklopadie," Artikel Masern. 



662 MEASLES, MORBILLI, RUBEOLA 



TREATMENT 

"When the first case of measles has appeared in a family or has arisen 
in a school, kindergarten or children's asylum, the question that should be 
primarily asked is whether and how the dissemination of the disease may 
be prevented. The endeavors directed to this point are usually made illusory 
by the circumstance that the diagnosis of the first cases during the first days 
of the disease cannot be made and, therefore, the surroundings of the first 
patients are already exposed to the contagion before we are in a position to 
adopt prophylactic measures. Thus, in an institution, the disease is not 
limited to a single case, but a larger or greater number follow and the prophy- 
laxis can only then consist in closing the entire institution. In the family, 
here and there in an existing epidemic, a probable diagnosis may be made 
in the first hours and then, eventually, other cases may be prevented from 
arising. 

This may be done if the sick child is brought into a special room, particu- 
lar utensils being used for nutrition and nursing and in having special nurses 
at hand. Then an isolated service for the patient must be carried out strictly, 
and all communication between well and sick children, particularly also among 
the surroundings, for at least three weeks must be absolutely restricted. 
Under such circumstances I have succeeded sometimes in isolating the indi- 
vidual case. If we are dealing with one or more very young or even weak 
children the attempt ought to be made to isolate the patient. The circum- 
stance is different if a family is threatened, the members of which have 
advanced beyond the first years of childhood; in such cases I do not regard 
a strict isolation as necessary, as measles, particularly during the first years 
of school life, is combined with comparatively slight risks, as it is very 
unlikely that an individual child will entirely escape the affection for life. 
Whereas, in consideration of the same thoughts, the places at which small 
children collect (day nurseries, kindergartens, asylums, etc.) are to be closed 
when measles has appeared in these institutions, such a necessity does not 
exist in the case of schools — except a particularly malignant epidemic is 
prevalent at the time which would require such a protective measure. 

The treatment of simple uncomplicated measles may be a purely die- 
tetic one. 

It must only be remembered that the disease, on account of a decided 
implication of large areas of mucous membrane, has a catarrhal character, 
and that in this respect care is necessary. All possibility of refrigeration, 
sudden cooling of the skin, wetting without sufficient drying, particularly 
draughts, are to be avoided. On the other hand, nothing is more important 
for the favorable course of measles than the entrance of pure fresh air into 
the sick-room. Both requirements must be carried out by careful nursing, 
although they appear to conflict with each other. 

In persons living in poorer circumstances, even in winter it should be 



TREATMENT 663 

insisted upon that a window should remain somewhat open in the sick-room 
day and night. To prevent a threatening draught a curtain may be hung 
in front of the window and the bed moved away. According to the means 
of the patient, these conditions can be carried out better and better until 
finally two rooms may be had for nursing, the one being used during the 
day, the other at night, so that the one room may be constantly aired while 
the patient is in the other room. The patients usually ask for the exclusion 
of daylight on account of the conjunctival catarrh. This request should be 
granted but without completely darkening the room, which is still done in 
some families. By the necessary light which is required from time to time, 
the eye is only more intensely irritated; and, above all, a necessary airing 
under such circumstances is impossible. 

The temperature of the sick-room may be somewhat higher than in other 
fevers, about 68° F., but not too high, because the dryness which readily 
occurs under those circumstances directly damages the larynx and trachea. 
The skin should rather be kept slightly perspiring by the frequent adminis- 
tration of luke-warm drinks (various forms of tea) than be too dry. The 
necessary washings are always to be carried out with care, member after mem- 
ber being cleansed and very carefully dried. Bathing had better be avoided 
in measles — in so far as it is not necessary for curative purposes — on account 
of the possibility of refrigeration. Changing the linen must be carefully 
performed, this being warmed before being placed upon the child. All these 
precautionary measures are necessary in the period of convalescence as well 
as in the preceding period, up to the end of the second week. Except in mild 
cases the patient should not be allowed to leave his bed before two weeks, 
preferably not before three weeks; and the patient should stay in the room 
except in warm sunny weather for at least four weeks. This rule is often 
broken without consulting the physician and without producing harm; but 
I know of many cases in which the transgression of this measure has avenged 
itself, often enough seriously. Even after leaving the bed or the room the 
regained health remains in an unstable equilibrium for a varying time ; great 
care must be taken to prevent the convalescent from coming in contact with 
tuberculous patients or their emanations for at least three months. 

The nourishment should be fluid during the fever and consist of milk, 1 
which, in children that are averse to taking milk, may have a few drops of 
coffee or cocoa added. As soon as the fever has disappeared and appetite 
returns, if there is no contraindication on the part of the intestinal canal, 
wheat bread and butter, meat soups, fruit soups may be given, later vegetables, 
cooked meat and zwieback, finally, bread and potatoes. 

i The advice to restrict the diet to milk, in the fever of measles, to children of the 
age in which the eruption is met with, is of doubtful value. It is not digested even 
when relished, in such quantities as are required. Indicanuria at least is a frequent 
occurrence. The addition of coffee does not improve the taste for children who have 
been correctly brought up without coffee. The addition to milk should be cereals, on 
account of their nutritive value and their antifermentative effect. — Editor. 



664 MEASLES, MORBILLI, RUBEOLA 

After leaving the bed and a few days after leaving the room a cleansing 
bath is given. 1 

The catarrh of the mucous membranes requires treatment. The eyes are 
to be washed every morning with boiled water, to loosen the adherent lids, 
and they are then to be moistened with a salve, such as a zinc salve or a sim- 
ple glycerin salve; simple catarrhal conjunctivitis needs nothing further. 

The coryza requires no other treatment than frequent cleansing of the 
nose with small swabs of cotton, and protecting the lips by a glycerin salve. 
This salve is to be recommended on account of its permeating into the upper 
layers of the epidermis and keeping them moist. By ear specialists (Weiss) 
it has been lately advised to use a small swab of cotton moistened with a 
J per cent, silver nitrate solution and introduced several times daily into the 
nose, the fluid being expelled by slight pressure so that the fluid slowly flows 
to the choana and the pharyngeal cavity. This is said to prevent infection 
of the tubes and otitis media. 

The oral cavity is also to be cleansed several times daily, in older children 
by spraying or gargling, in younger children by gently spraying, a measure 
which is certainly not without influence in the prevention of secondary bron- 
chial and pulmonary affections. If the skin itches it may be anointed 
with a lanolin salve with the addition of 1.0 per cent, thymol several times 
daily. 

With this dietetic treatment in uncomplicated measles we may get along 
without a drop of medicine. At most a stubborn cough which prevents the 
child from sleeping may render necessary the administration of some syrup 
of ipecac with about 0.005 to 0.02 sulphate of codein to 50 grams of water, 
a teaspoonful being given three or four times daily. 

However, if complications arise the physician must not content himself 
with this expectant plan but must adopt energetic measures even though 
here for the most part the physico-dietetic method is also prominent in the 
treatment. 

In excessively severe catarrh of the eyes, after a careful cleansing of the 
conjunctival sacs several times daily, the palpebral conjunctiva should be 
painted with an 0.5 per cent, to 1 per cent, silver nitrate solution (followed 
by cleansing with boiled water) ; in the interval, under some circumstances, 
ice treatment is necessary or the application of corrosive sublimate (1 to 
4,000) and if the cornea is threatened, repeated dropping of atropin (0.03 
to 10). The e} r elids are to be rubbed with Pagenstecher's eye-salve (Hydrar- 
gyr. oxydat. flavum 1 : 10 Ungt. paraffin, or TTngt. leniens). 

With an intense marked swelling of the mucous membrane and submucosa, 
with excoriation and profuse secretion, combined with the coryza, the insuffla- 
tion of Moritz Schmidt's nose powder is to be recommended (three times 

i In regard to bathing, which is incidentally recommended (p. 663) in the third 
week or later, Americans, both professional and lay, have a different opinion and prac- 
tice. We bathe sooner, on general principles, and to remove the contagion contained 
in the desquamating epidermis. — Editor. 



TREATMENT 665 

daily) : Menthol 0.5, sodium sozojodol. 1.0 to 2.0, and 20.0 pulvis sacch. 
Or the careful pouring into the nasal cavity of hike-warm thymol water J to 1 
per cent, by means of a teaspoon (not to be injected!), or the squeezing from 
a tampon of cotton which has been moistened with a ^ per cent, solution of 
silver nitrate. The surroundings of the nose and the upper lip must be pro- 
tected by the inunction of a covering salve. 

Inflammations of the oral cavity, particularly the aphthous forms, besides 
careful cleansing, require painting with a 2 per cent, to 3 per cent, solution 
of carbolic acid several times daily. The nurse should be informed that the 
brush is never to be dipped into the bottle, but a few drops should be poured 
out into a spoon or bottle or the like and then used. 

The first development of noma or cancrum oris is to be treated by an im- 
mediate excision of the diseased area, followed by the use of the thermo-cautery. 
von Eanke has cured three cases in this manner. The condition of the ear 
requires the greatest attention. It is not necessary after the presence of an 
otitis media has been discovered by means of the speculum that paracentesis 
be at once performed. Non-purulent catarrhs of this form recover spontane- 
ously, purulent ones often rupture spontaneously. The introduction of a drop 
of 5 per cent, to 10 per cent, carbolic glycerin solution and the application of a 
Priessnitz poultice over the anointed ear are frequently sufficient; but it is 
necessary to watch the condition carefully as if, with a continued fever upon 
the first or second day no spontaneous opening of the membrane occurs, para- 
centesis must be performed. Even afterward the ear must be carefully 
watched, fresh rises of the temperature, redness, or even pain in the mastoid 
process, or a possible enlargement of the lymph glands at the anterior or 
posterior borders of the bone must be looked for so that the diseased portions 
of the bone and its cavities may be early opened. 

The respiratory organs require treatment even more frequently than do 
the organs of hearing. 

In the severe forms of laryngitis in which the submucosa is implicated 
the methods described below which produce diaphoresis are to be utilized. 
Local application of heat in the form of poultices, measures which redden 
the skin, application of mustard plasters, painting with iodin are not to be 
undervalued. In these cases if we are dealing with somewhat strong individ- 
uals, or, better, with constitutions that are not too much weakened, I advise 
local blood-letting. One or two leeches are applied to the region of the larynx 
and, according to the condition of strength, the subsequent bleeding is assisted 
for a longer or shorter time so that 40 to 60 grams of blood are withdrawn. 
Amelioration always follows this measure and frequently it prevents the devel- 
opment of a serious process. While this measure is being carried out we 
should never neglect to have the air which is inhaled by the patient in a pure 
but uniform moist condition (this is best done by repeated spraying at the 
bedside). 

In disease of the bronchi and lungs the various hydrotherapeutic measures 
are utilized to advantage. In catarrh of the larger bronchi and even in 



666 MEASLES, MORBILLI, RUBEOLA 

bronchiolitis, Priessnitz compresses changed three to four times daily are very 
grateful to the patient. According to the height of the fever, they may even 
be repeated more frequently and then have a cooling action, if the moistened 
sheet is not covered with india rubber tissue but only the woolen blanket is laid 
over it. 

In severer cases, measures which redden the skin and diaphoretics are to 
be used. In cases in which the eruption appears tardily or insufficiently or 
in which it disappears rapidly, whereas increasing dyspnea, etc., denotes disease 
of the lung, an artificially produced friction of the cutaneous vessels may 
bring about improvement. According to the condition and strength of the 
patient, various methods may be adopted. In very weak children the adminis- 
tration of hot drinks, eventually also of a small dose of pilocarpin x internally 
(5 milligrams to 1 centigram), dry enveloping of the whole body, with the 
exception of the head, in a woolen blanket are of value, these measures being 
continued so long as sweating in the face occurs; this is followed by careful 
loosening of the coverings, thorough drying and rest. In stronger children 
who can stand some heat and in whom a decided irritation of the skin can be 
endured, the body is first wrapped in a moist sheet, a woolen blanket being 
placed over this, and the patient thus enveloped then has another covering 
placed over these so that sweating occurs as soon as possible. 

The " derivative " method is more effectual (in a distributed capillary 
bronchitis, for instance). This consists in the following: About \ kilogram 
of fresh ground mustard is placed in 1 litre to \\ litres of warm water and this 
is stirred until the oil of mustard develops sufficiently to begin to irritate the 
eyes and nose. Then a sheet large enough to envelop the entire body is dipped 
into this mustard water, wrung out and wrapped about the naked body of the 
child. Or, as in the above case, simple moist linen is used, a woolen blanket 
being placed over this. This process has the advantage over the mustard bath 
in that by this method the irritating fumes are not inhaled by the lungs. 
Where a good reaction has occurred the entire skin of the child up to the neck 
will be as red as a boiled crab after fifteen to twenty minutes. Now the mus- 
tard wrappings are removed and the child is simply enveloped in moist cover- 
ings until a good sweating takes place (in from one-half to one hour). The 
coverings are then removed and the little patient is placed for a short time in a 
luke-warm bath. If the temperature has risen in the meantime, cold effusions 
are poured over the chest, head and neck, this being followed by a thorough 
drying and rest. 

This process, at least for the first time, must be superintended by the physi- 
cian. The last described process is somewhat tedious, but shows surprising 

i " In very weak children the administration of ... a small dose of pilocarpin inter- 
nally (5 milligrams to 1 centigram) is recommended when the eruption appears tardily 
or insufficiently or in which it disappears rapidly." One sixth of a grain of pilocarpin 
is a big dose for a strong adolescent or adult. To give it as above recommended to 
" weak " children seems to me a mistake. I had an extensive experience with the drug 
thirty years ago. A strong heart is weakened by it, a weak heart is endangered. — 
Editor. 



TREATMENT 667 

results; however, it must not be repeated too frequently, at most but once a 
day, and the child must have complete rest after that for a long time. If after 
one or two applications the condition of the lungs has not become better nor 
the eruption more prominent I do not employ the method any further. Xo 
good reaction is obtained after the third or fourth attempt and the strength of 
the child is unnecessarily wasted. However, in cases in which the desired 
reaction occurs, a repetition upon several succeeding days may be of value. 

In place of, or alternating with the derivative diaphoretic procedures, to 
stimulate inspiration or to bring about deep inspiration which is then followed 
by strong paroxysms of coughing, cold affusions in the warm bath may be used 
in the same manner as they are applied in connection with a desired diapho- 
retic action. According to age, children remain from two to three or five 
minutes in a warm half bath, of a temperature of 93.5° F., cold affusions (5 to 
6 litres in all) being poured over the chest, head and neck. The openings of 
the ears are to be closed with plugs of cotton. These cold affusions are also of 
decided use in cases with high fever in which there is marked somnolence, 
delirium and dry tongue. With a small pulse some alcohol may be given before 
and after the bath and these baths may be given from four to six times daily. 

The action of emetics in bronchitis of the finer tubes is somewhat uncer- 
tain. TVine of antimony is best for this purpose, of which a teaspoonful may 
be given every quarter of an hour until vomiting occurs, but previous to this 
the child should have a plentiful amount of some warm drink. Local blood- 
letting in strong children is perhaps more often in place than we are inclined 
to assume just now. I have had no experience in regard to this. Finally, it is 
still to be emphasized that in some cases of pulmonary inflammation in measles, 
with prolonged fever, the so-called antipyretic drugs are of unquestioned value. 
Here, under some circumstances, they appear to have an antiphlogistic action, 
in so far as by their administration not only the fever falls but the local phe- 
nomena improve and recovery takes place. The following temperature chart 
(Fig. 24) shows a case of this kind in which antifebrile medication appeared 
to me to be of decided value. 

Thallin 1 was used at that time in the form of injections into the rectum 
(5 grams of a 5 per cent, solution). Xow antipyrin had better be used for 
the same purpose, 5 centigrams or 2 decigrams daily, according to the age 
of the patient, or salicylate of sodium 0.1 to 0.5 several times daily, or aspirin 
in the same dose. It is impossible to say beforehand in which pulmonary 
complications in measles this medication will be effective. Sometimes it is 
ineffective, at other times success appears to be marked, but these measures 
are not to be continued long provided no favorable influence results. 

In those cases in measles in which the intestinal phenomena take on a 
special character, it is valuable, besides the administration of a starchy diet 
(for example, some of the commercial infant foods), to give for a half or an 

i Thallin should remain in its grave. Phenetedin (phenacetin) is preferable to anti- 
pyrin.. which is liable to cause too much perspiration. It may be combined with caffein 
or (when there is any cerebral irritation) spartein sulphate or camphor. — Editor. 



668 



MEASLES, MORBILLI, RUBEOLA 



entire day, every two days, repeated small doses of castor oil (one-half to a 
teaspoonful) followed by an oily emulsion containing a small quantity of 
opium. The treatment of nephritis will be described under scarlatina. 

Regarding the treatment of sequels and complications, they cannot be con- 
sidered in detail here. Only two points are to be emphasized. The great 
danger to the patient suffering from measles complicated by a diphtheritic 
affection has already been mentioned, therefore, upon the first suspicion the 
specific treatment for diphtheria is to be used in large and repeated doses 
(3,000 antitoxin units several times). Besides, it is advisable to at once 
immunize brothers and sisters of the patient and to repeat this immunization 
during the duration of the disease and the convalescence (which lasts about six 



Dec. , 

l.SHti * 


I 3 4 5 6 7 8 9 10 11 12 


13 14 15 16 17 18 19 20 21 22 


T. 


12 3 4 5 6 


7 8 9 10 11 12 13 14 15 16 


Fahr. 


4 ^ h 


Cent. 
V -r- 40° 


-irko o° 


1^ S/ 


„_\A L 


102.2 


I M I 


v \ 


100.4 


""V I 


\ > 38 

TV V 

Thilln 1.251 




Exanthera 


Disseminated Bronchiolitis 
and Catarrhal Pneumonia 



Fig. 24. — Temperature Chart in Malignant Measles, Showing Pulmonary 

Complications. 



weeks) every fourteen days. The same is true of measles occurring in hospitals 
where the patients cannot be strictly protected from an infection with diph- 
theria. The experiences in my clinic have shown that by this methodic im- 
munization, diphtheria which was nearly endemic in the measles pavilion has 
almost entirely disappeared. It is true we had to shorten the intervals between 
the immunizing injections to less than three weeks, for a number of times 
severe infections with diphtheria occurred fourteen to sixteen days after the 
immunization; it thus appears that the antitoxin in the case of measles in 
particular is rapidly excreted. 

Finally, it is to be emphasized again that in all cases of measles where 
there is a predisposition to tuberculosis (occurrence of a case of tuberculosis 
in the family) or where local tuberculosis has already occurred (so-called 
scrofulosis), the convalescents instead of being isolated for but three or four 
weeks are to be looked upon as half convalescents for several months and as of 
very unstable health and their resistance must gradually be increased by good 
nutrition, residence in fresh pure air and exemption from any laborious activ- 
ity before they again return to the dangers of ordinary life. To recognize the 



TREATMENT 669 

time when this period has arrived is perhaps possible by an estimation of the 
body weight, either after the previous weight has been reached and maintained 
permanently for several weeks or after the child has been brought up to the 
average weight of its age and maintained at that. 

The erection of homes for convalescents in connection with hospitals is an 
obvious necessity in order to attain this end, especially in case of the poorer 
classes of the population. 



SCARLET FEVER, SCARLATINA 

By O. Heubner, Berlin 

ETIOLOGY 

Scarlatina is an acute, infectious, contagious, febrile disease, character- 
ized by a scarlet-red cutaneous eruption and by inflammation of the pharyn- 
geal organs. The synonyms of the disease in all civilized languages call par- 
ticular attention to the peculiarity of the eruption. 

But little that is certain is known regarding the history of scarlatina. If 
we reflect how conspicuously the cutaneous coverings of the body are altered 
by this affection, it does not appear possible that mention of this disease should 
have been overlooked in the writings of the Arabians and of the ancient physi- 
cians. Descriptions from which the disease may be recognized are only found 
in medical literature in the second quarter of the seventeenth century (by the 
German physicians, Sennert and Doring). Sydenham in the last quarter of 
the same century clearly recognized the peculiarities of the disease. 

Observations of the disease showed from the onset a very peculiar change- 
able character in succeeding epidemics, a diversity which hardly occurs in any 
other affection. Sydenham, in 1664, did not attribute greater importance to 
the disease than we show nowadays for rubella (rotheln), and fifteen years 
later, in the sphere of activity of this great observer, in London, the affection 
appeared with a severity which was only equalled by the bubonic plague. And 
if one hundred and fifty years later Bretonneau, a physician of like importance, 
declared that a scarlet fever patient only died when treated incorrectly, a few 
years later, when in the presence of an epidemic in which a frightful mortality 
took place, he was compelled to acknowledge how greatly he had been mistaken. 
An instructive picture of this periodic, very varying course of the affection, 
occurring in the same population, is presented by a diagrammatic table of the 
mortality from scarlatina in Hamburg, compiled by Reincke. 1 

The great calamity from which Hamburg suffered in the years 1821, 1831, 
1852 and again in 1878 and 1879 from scarlatina is readily recognized, and 
between these periods there are again very decided diminutions in the danger 
from scarlatina. The punctuated line added from 1872 on, signifies (in -yV the 
scale) the morbidity curve (in so far as it could be determined from the report 

i " Die Gesundheitsverhaltnisse Hamburgs im neunzehnten Jahrhundert." Hamburg, 
Sept., 1901, p. 169. 

670 



ETIOLOGY 



671 



of physicians). It will be noted that the severity of the individual epidemics 
and the morbidity are by no means parallel. Wherever exact statistical reports 
have been attained, for example, in Norway, according to the investigations of 
Johannessen, which cover a period of sixteen years, it is noted that the affection 
everywhere shows this very remarkable character of rise and fall of the grade 
of malignancy. In these observations the morbidity and mortality run quite 
parallel. It is difficult to recognize this property as a consequence of a varying 
virulence of the pathogenic agent, it is more probable that other auxili- 
ary causes periodically and decidedly increase the susceptibility of the popu- 
lation. 

Scarlatina owes its origin to a poison that proliferates anew solely in the 
human being attacked by scarlatina, whereas outside of the human organism 
it is capable of maintaining itself in a condition in which it may increase (as 
a pathogenic organism) but is scarcely ever able to actually proliferate. Pre- 
vious views, according to which the scarlatinal poison is said to develop in 



Mortality 


~m CO *^ CO ^J CO ^* tO ^^ CO ^* CO ~+ tO ^ JO O 
-NJ^COM^^ *5 lO. CO CO t- r~ 30 30 Oft OS O 

3o 3o ao oo oo "ao aoaooocoaosoogaoaoaoci 


Morbidity 


/oo 

2.0 
1.5 
1.0 
0.5 






































/oo 

20 
15 
10 
5 


4 


\ 








\ 


















| 




i 






| 














1 




J 




1 














A 


\ 




1 


A 




,\\ VK 










I 


J 


I 


j* 


h 


I 




yf/y 


y. 








■ 





Fig. 25. — Mortality of Scarlet Fever from 1821 to 1900. 



an autochthonous condition outside of the human body, are based upon the 
observation of cases in districts in which for a long time no case of scar- 
latina has occurred and also in which no cases were imported. However, since 
we know that, under some circumstances, the transportation of the poison of 
the disease may occur by means of healthy individuals, certainly by those that 
have but a mild degree of tonsillitis, in which the patient does not regard 
himself as sick, these experiences are no longer tenable with the law of unquali- 
fied contagion. 

Of "Oris poison, which is renewed year after year in thousands of people, 
and increases, as little is known regarding its nature as of measles. Since the 
beginning of the bacteriological era there have been many observers who looked 
with more or less certainty upon the chains of cocci, which were almost always 
found in the pharynx of scarlatina patients and very often in the blood and 



672 SCARLET FEVER, SCARLATINA 

the tissues of the cadaver, as the pathogenic agents of scarlet fever. The 
majority of these observers, similar to Sorensen, are probably of the opinion 
that it is not a parasite which is identical with the streptococcus pyogenes, but 
that it is a microbe which morphologically resembles the usual streptococcus 
and one that possesses a special specific character, the property of producing 
a particular disease. Up to the present, no examination of the streptococcus 
found in scarlatina has shown the specific property of the germ. Moreover, 
it has been shown that in all points which can be determined it resembles the 
streptococcus erysipelatos. 1 In the streptococcus of scarlatinal angina, Hilbert 
was not even able to determine the property of secreting toxins which Baginsky 
and Sommerfeld had maintained. The constant occurrence of this microbe in 
the blood of recent scarlatinal infections (or at the autopsy) could not be dem- 
onstrated by Bohm in Baumgarten's Institute, nor by Slawyk in my clinic. 
Naturally, all tissues were not examined. Perhaps it will be possible by more 
accurate bacteriologico-biological investigations to solve this question. 

[Class recently demonstrated in the secretions of the throat, in the blood 
and in the desquamating epidermis, a diplococcus which was pathogenic in 
mice, swine and guinea-pigs. 

Baginsky and Sommerfeld have described a streptococcus. Later, Baginsky 
and Monti showed the presence of streptococci in short and long chains almost 
constantly associated with other organisms, as pneumococci, staphylococci, and 
forms of diplococci in smears from the pharynx. The urine, and in two cases 
the fluid withdrawn by lumbar puncture, contained streptococci. From the 
autopsy material studied, the streptococcus was isolated in every instance and 
almost always in pure culture. These observers do not commit themselves in 
regard to the causal relation of the streptococcus to the disease. The hypothe- 
sis that scarlet fever is a streptococcus disease does not receive direct support 
from recent studies of the blood by Hektoen. This observer made bacterio- 
logical examinations during life, especially in regard to general streptococcus 
infection. He states that streptococci may occasionally be found in the blood 
in cases of scarlet fever that run a short, mild and uncomplicated course ; that 
streptococci are more frequent in the severe and protracted cases ; and that they 
are not found in some of the fatal cases. Very recently Mallory has demon- 
strated the presence of very remarkable segmenting bodies in the tissues of 
cases of scarlet fever. — Ed.] 

We are better informed regarding the manner of distribution of the scar- 
latinal poison than of its nature. Our northern colleagues who have had an 
opportunity of studying the disease upon isolated islands or in villages situated 
in the woods in which little communication existed, have been able to supply us 
with valuable points. 2 Especially the epidemic in Lommedalen, studied by 

i In 1888 my pupil, S. Lenhartz, succeeded in producing an erysipelatous affection 
in mice by means of a streptococcus cultivated from scarlatinal blood. {Jahrb. f. 
Kinderheilk., Bd. xxviii.) 

2 Hoff, " Erfahrungen auf den Faroerinseln iiber Scharlach." Quoted by Jiirgensen, 
Scharlach in NothnageVs Handbuch, iv, 3, 2. Abth., p. 3. 



ETIOLOGY 073 

Johannessen, 1 is particularly instructive, because this author had an oppor- 
tunity of observing the entire population, amounting to 533 persons, in a vil- 
lage near Christiania, so that not even the mildest case of scarlatinal angina 
could escape him. From these observations, the individual points of which 
cannot here be entered upon in detail, it could be seen that nothing but human 
intercourse, and only this, is capable of distributing scarlet fever. Most fre- 
quently it is the mild or not severely affected patients that communicate the 
disease to susceptible healthy individuals ; and the most dangerous transmitters 
are those adults in whom the disease often exists as an angina (tonsillitis) 
which is not even accompanied by fever. Thus the entire epidemic, in the 
previously mentioned lonely Norwegian village, was produced by a servant girl 
aged twenty-nine who had nursed a scarlet fever patient in Christiania, and 
being attacked by angina tonsillaris, on the third day of this disease returned 
to her home situated in the midst of a forest, four hours from Christiania. She 
was not ill enough to take to bed, but was out daily. She spread the contagion 
to her own and to other families and from these foci the disease was distrib- 
uted to over 24 families that lived quite distant from one another, attacking in 
all 67 j)ersons, or 13.9 per cent, of the entire population, in so far as they were 
not protected by a previous attack of scarlatina (44 cases). 

In large cities, in the greatest majority of cases, the first flaring up of an 
epidemic occurs by infection in the schools. Those attacked take the disease 
home with them and transmit it. Among the schools, all those places are to 
be included in which a large number of children are thrown together : there- 
fore, kindergartens, infant institutions, asylums, etc. Children's parties not 
infrequently give an opportunity for transmitting the disease. In by far the 
greatest number of all transmissions, the active agent has naturally not yet 
been recognized as a scarlatina patient, either because the affection is so mild 
that there is no thought of a severe foundation of the scarcely noticeable 
throat difficulty or because the patient is only at the onset of the disease. How 
frequently does it occur that children, on account of sudden illness and vomit- 
ing, are sent home from school, are put to bed and develop scarlatina. During 
this onset of the disease they have had an opportunity of transmitting the 
malady to their susceptible neighbors. A second category of infection occurs 
at the termination of the individual disease. After a fortunate recovery from 
the affection the little patient is looked upon as completely well if he has re- 
gained his former strength, appetite and sleep, and no more of the pathological 
changes can be found in him. The patient, even as regards his own sensations, 
has recovered, but in spite of this the poison still adheres to him. It is not to 
be doubted that this is still the case up to the end of the sixth week after the 
onset of the disease. A child that had completely recovered from scarlatina, at 
the end of the sixth week, on account of the still existing discharge from the 
ear, was sent from my scarlatina division in the hospital to the ear department 

1 Johannessen, " Gut abgegrenzte Scharlachepidemie in Lommedalen." ArcMv f. 
Kinderheilk., Bd. vi, 1885. 
44 



674 SCARLET FEVER, SCARLATINA 

of the Charite. Four days later his neighbor was attacked by scarlatina. Simi- 
lar experiences in greater numbers may be gathered from the return of chil- 
dren to their own families, that have recovered from scarlet fever in the hospi- 
tal, even if the proof of a causal connection between a new affection and conta- 
gion by means of the convalescent cannot be shown with certainty. Xow, the 
question may even be propounded, whether the sixth week is the final period in 
which a convalescent is no longer dangerous. Usually the desquamation of the 
epidermis, which lasts until this time, and may even continue longer, is 
looked upon as the danger period for infection, and the scales themselves are 
supposed to be the carriers of the poison. This assumption is by no means 
proven. It is just as likely that the poison is contained in the pharyngeal 
organs, in the pus from the ear, in the urine, or in other excretions. 

In fact, even of the recent scarlatinal case, it is by no means known with 
certainty regarding the seat of the contagion, whence it disseminates itself 
and how it leaves the body so that it is capable of entering a second organism. 
Clinical experiences render it quite likely that the first point is the mucous 
membrane of the pharyngeal organs, perhaps, also at least at the onset, this is 
its principal point of reproduction. The transmission appears in quite a 
number of cases to occur in a fleeting manner, i. e., without direct corporeal 
contact, kissing, shaking of hands, etc. The expulsion of sprays of saliva from 
the mouth of the patient in speaking, which is pointed out by Fliigge, may be 
the method of transmission of the infection. Probably more frequently, espe- 
cially in the case of younger children, the introduction of the finger or other 
substances which have come in contact with the poison, into the mouth of the 
healthy brings about the contagion. This mode of transmission is facilitated 
by the property of the scarlatinal poison of adhering to fomites, such as toys, 
books, tools, which a scarlatinal patient has used, for some time, also to letters, 
linen, beds, clothes, etc. Food substances also, in case they are not heated 
before use, such as cakes, and especially milk, may retain the scarlatinal con- 
tagion. That the poison may remain in rooms, on the wall paper, in hallways, 
and even apparently after thorough disinfection, has been proven by the fre- 
quent unfortunate experiences in cases where children have been away from 
home and upon returning have been taken sick in a carefully cleaned room. 
The other possibilities, however, also remain open that the poison may still 
adhere to the body of the apparent convalescent or perhaps may adhere to the 
nurses or parents that have shown but a slight attack. That a healthy person, 
and a healthy third person, may be the carriers of a contagion will probably 
belong to the rarest possibilities, but that this does occur cannot be doubted. 
Johannessen communicates an unquestionable case which, in my opinion, 
shows this mode of transmission. It is that of a servant girl whom he himself 
had treated two }^ears previously for scarlet fever, and who at the time of 
transmission .did not even show a slight angina. It appears, however, that 
only such persons are capable of transmitting the disease as remain in the 
immediate vicinity of the patient, as nurses or servants, and who also come 
in contact with susceptible healthy persons for a prolonged time. 



ETldLOGY 675 

The point at which the poison is taken up on the part of the attacked indi- 
vidual, as has been mentioned, is most frequently the posterior portion of the 
naso-pharyngeal space and the oral cavity. Besides this, however, the scarla- 
tinal poison has the peculiar property of utilizing interruptions of continuity 
in the skin as the ports of entrance to the organism. A varicella pustule which 
has been scratched, a wound upon the penis in a phimosis operation, an acci- 
dental tear of the ringer, may be the first points of attack of the scarlatinal 
infection. Puerperal scarlatina also finds its entrance by way of the smaller 
or larger injuries upon the genitalia, due to childbirth. In such instances, 
first the wound assumes an unhealthy appearance, the borders showing a 
smeary or membranous coating, then the surrounding area becomes red, and 
thence the general cutaneous eruption begins to develop itself. The circum- 
stance that in the coating of the wounds in such cases, especially in pregnant 
women, streptococci are always found, Sorensen quotes in proof of his assump- 
tion that this streptococcus possesses etiological connection with scarlatina. If 
only the streptococcus were not the principal factor in most of the other puer- 
peral processes even in those in which scarlatina does not come into question 
at all! 

The susceptibility of the human race at this time is limited ; perhaps in this 
connection not all people and races are alike, even individual families appear 
to possess absolutely no resistance toward scarlet fever. Under certain external 
influences (the season) the susceptibility may be increased. But everywhere 
adults are more resistant than children. Scarlatina, in a much narrower 
sense than in the case of measles, is a disease of childhood. Johannessen saw 
in Lommedalen 28.1 per cent, of children, 5.1 per cent, of adults, attacked (in 
the families in which contagion occurred, 36 per cent, of the children and 82 
per cent, of the adults remained free). In childhood the susceptibility is 
greatest between the third and fourth years of life, but remains high, how- 
ever, up to the tenth year and then declines. Nurslings are much less suscep- 
tible, especially in the first half of the first year of life. I have never seen a 
positive case of scarlatina in a child under six months of age. (A case recently 
reported by Kroner, 1 in which a child aged seven weeks was said to be attacked 
by scarlatina, is somewhat doubtful.) 

Eecovery from the disease in the greatest majority of cases, confers immu- 
nity toward new infection, certainly up to the adult age, when the suscepti- 
bility becomes lessened of itself. But the protection against scarlatina appears 
to me to be slighter than in the case of measles. Among 359 cases treated by 
me in Leipzig, I met with 6 cases that had been treated for scarlatina, by 
competent physicians that were known to me, and that only five years pre- 
viously. Two of the cases were merely attacked by severe angina, while a 
brother at the same time succumbed to a fatal attack. 

The period of incubation of scarlatina is liable to greater variations than 
any of the other acute exanthemata, but in the main it appears to be a short 

i Deutsche med. Wochenschr., Nr. 51, p. 896. 



676 SCARLET FEVER, SCARLATINA 

one. The well-known case communicated by Trousseau ! — provided there were 
no source of error — would show a period of incubation of twenty-four hours, 
the most usual duration of the period of incubation will be found to be between 
four and seven days. 

PATHOLOGY 

The pathological changes occur particularly in the mucous membrane of 
the pharynx and in the skin. The changes in the kidneys will be described 
later on. 

In the pharynx, in the milder cases, there is a very decided hyperemia of 
the mucous membrane and a hyperplastic process in the entire adenoid sub- 
stance. As well in the larger deposits of this tissue, in the pharyngeal and 
palatine tonsils, as everywhere in the separated follicles of the mucous mem- 
brane, at the base of the tongue, of the lateral and posterior wall and at the 
entrance of the pharynx, a distinct increase is noted in the lymph cells filling 
the fine fibre net. The same condition occurs in the lymph glands in this 
region belonging to the inframaxillary and retropharyngeal region. The sharp 
limitation of the inflammatory hyperemia of the mucous membrane of the 
esophagus and entrance to the larynx, which may still be recognized in the 
cadaver is noteworthy and characteristic. Particularly in the first-mentioned 
area, the hyperemia terminates in an abrupt straight line. The upper surface 
of the mucous membrane is found to be in a catarrhal condition with a muco- 
purulent exudation, especially upon the surface of the tonsils. 

In the severe cases, which terminate fatally in from one to four days, this 
acute hyperplasia of the lymphatic tissue is often found developed to an enor- 
mous extent over the entire body. Not only the peripheral lymph glands 
upon the neck, those in the axilla and in the inguinal region enlarge, but 
also those throughout the entire intestinal tract, as well as all the lymph 
follicles, all Peyer's patches, the mesenteric glands, and even the spleen are 
enlarged to a similar extent; upon section this latter organ shows medullary 
swelling, it is pulpy and coarse. New formations of small lymph nodes are 
found in the liver and in the kidney. The last-mentioned organs in these 
cases appear markedly hyperemic, here and there small hemorrhages are 
found, particularly near the surface. According to van den Berg, 2 the blood 
with but few exceptions shows a hyj)erleukocytosis which lasts for several weeks 
and is due to the polynuclear elements. The heart in the rapidly fatal cases 
is usually flaccid and pale; but also quite firm and markedly contracted left 
ventricles are noted. 

In cases of a slight or medium severe infection, the more locally limited 
inflammatory disease of the mucous membranes and lymph gland enlarge- 
ment diminishes in the second half of the first week or in the beginning of 
the second week, even though, subsequently, in one or the other gland, a more 

i Med. Klinik des Hotel Dieu, 2te. Aufl., German by Culmann, Bd. i, p. 98. 
2 Arch. f. Kinder heilk., Bd. xxv. 



PATHOLOGY 677 

substantive inflammatory process may develop. In very many cases, however, 
the serious turn which the affection takes occurs in the pharyngeal organs. 
The simple severe inflammation then changes its character and leads to an 
inflammatory necrosis of the tissue, by the formation of a coagulated, simulta- 
neously hemorrhagic, exudate. Partly (but usually not to a marked extent) 
this is found upon the surface of the mucous membrane, between and beneath 
the epithelium, in the form of thin, often disconnected membranes, partly to 
a slighter, at other times to a more marked extent, in the tissue of the 
mucous membrane and in the adenoid layers. But even there this inflamma- 
tion (in an anatomical sense a true diphtheritic one) does not halt, but attacks 
the mucous gland layer situated beneath the mucous membrane, as well as the 
fat and muscular tissue, for example, of the palatine arch and uvula, of the 
epiglottis and of the larynx, altering everything into a rigid opaque mass, 
of which the original morphologic composition is no longer discernible. The 
inevitable result of this "coagulation necrosis." as it has been very aptly 
designated by Weigert, is the destruction of all affected parts. This inflam- 
matory necrosis also attacks deeper lying organs, especially the lymph glands 
situated near the pharyngeal parts, where it leads to the development of gan- 
grenous hemorrhagic foci, which again are a source of danger to the surround- 
ing areas, the cellular tissue of the throat. This tissue shows phlegmon- 
ous inflammation with widely distributed rigid tissue infiltration, with the 
formation of gangrenous foci varying in size. In the internal organs, 
especially the liver, circumscribed diphtheritic foci of slight extent may 
develop. 

It is remarkable that in this diphtheritic, or better — to differentiate the 
process from genuine diphtheria, with which etiologically it has nothing in 
common — diphtheroid inflammation of the pharyngeal organs, with extremely 
rare exceptions, in the cases that die during the first days of the disease, even 
though the adenoid conglomerations are as markedly hyperlastic as possible, 
nothing is found. The starting point appears to occur mostly upon the fourth 
day of the disease. 

The following case is an illustration of a beginning diphtheroid condition 
which has just been described. 

Swob., Albert, aged ten years, attacked upon June 13, 1888, in the afternoon, with 
high fever, limited eruption, delirium, unconscious upon the 16th, and died upon the 
afternoon of the 17th of June. 

The pharyngeal parts show a line of demarcation at the velum palatinum downward 
to the entrance of the esophagus, consisting of a sharp border of a dark bluish-red color. 
Inside of this area, upon the uvula, fine, hemorrhagic, punctiform regions may be 
noted. Upon the surface and in the lacuna of the left tonsil there is a muco-purulent 
coating. A section of the tonsil shows a marked medullary, swollen consistence of a 
reddish-white color. The same condition is noted upon section of the right tonsil, in 
its lower half. The upper half, however, shows a sharp demarcation compared with 
the lower, consisting of a high-graded, dark red discoloration, due to an inflammatory, 
hemorrhagic infiltration. A stream of water let fall upon it shows that the upper 
surfaces of the tonsillar swelling in these areas have separated and that a necrotic 
decomposition is beginning. 



678 SCARLET FEVER, SCARLATINA 

This diphtheroid process is combined with a very regular bacteriologic 
finding which is so constant that we may speak of a relation of the one to the 
other. Whereas in the first days it is impossible to find microbes in the micro- 
scopic sections, even in the markedly swollen tissues — their presence very fre- 
quently may be determined bacteriological ly — in the diphtheroid areas, great 
masses of streptococci are found, and not only this, they are found in the 
spaces of the tonsillar tissue and may even quite often be found in sections in 
the tissue of the lymph glands. 

Regarding the role which is to be attributed to the streptococci in this 
dangerous process, the opinions of those authors who deny an etiological con- 
nection between streptococci and the scarlatinal poison are still divided. Some 
look upon the serious change which occurs in the scarlatinal mucous mem- 
brane as the direct action of the previously mentioned microbes, which, already 
present to a lesser or greater extent in the oral cavity, find opportunity to gain 
a firm foothold upon the changed mucous membrane areas due to the scarla- 
tinal infection, and, entering the tissue, produce an inflammatory necrosis. 
Others believe that the scarlet fever diphtheroid is due to the action of the 
still unknown scarlatinal virus itself in especially susceptible individuals that 
have a weak mucous membrane, and only the necrosed tissue itself opens the 
tract for the massive proliferation of the cocci chains and their entrance into 
the organism. 

I favor the second view in regard to the circumstance that the diphtheroid 
mucous membrane disease — therefore, the beginning of the tissue necrosis, 
not the surface exudate ! — so commonly holds to a distinct phase of the course 
of scarlet fever and that streptococci in every case of scarlatina are present 
in the pharynx, diphtheroid, however, not always taking place. • A decision 
will only be possible after we have learned to recognize the scarlatinal virus 
with certainty. Practically of great importance, however, is this, that the 
streptococci after they have found an easy entrance into the organism affected 
by scarlatina become very potent in regard to the further course of the 
affection. The opponents of the law of the specificity of the streptococci must 
also admit that the resistance of the organ to the deleterious effects of the 
microbes in scarlatina is particularly slight, less than in almost all other dis- 
eases. For this reason, streptococcus sepsis plays such an ominous role in 
the prognosis of scarlet fever. At one time this shows itself in the form of 
severe phlegmonous inflammation of the throat, at other times the coccus 
infection is transmitted by way of the lymph tracts, again it creeps along the 
retrotracheal and mediastinal connective tissue tracts, at other times the 
coccus infection enters a vein and produces secondary pyemic blood disin- 
tegration, with multiple, purulent metastases in the most varied parts of the 
body. Scarlet fever pyemia, deviating from other analogous infections, shows 
the peculiar character that the joint cavities and the serous membranes are 
particularly predisposed to purulent deposits. In all cases of this kind we 
may speak of a proliferation of the streptococci through the entire body and 
in such quantities, very much greater than the relatively distributed germs 



SYMPTOMS 679 

which are found in recent scarlatina cases (without diphtheroid) even in the 
first days of the disease in the blood. The amount of streptococci in the blood, 
according to the investigations of Slawyk, 1 who worked in my clinic, observ- 
ing all necessary precautions, in general is parallel to the intensity of the 
diphtheroid mucous membrane inflammation, even if this is not the only 
point of entrance for the microbes, but may share this property with other 
inflammatory mucous membrane diseases, especially of the auditory canal. 

Slawyk found the blood, in 15 cases which terminated fatally on the third 
day of the disease, constantly sterile, only upon the fifth day of the disease 
the investigated cases showed, and then in decided quantities, streptococci 
in the blood. 

If it is true that streptococci do not produce toxin formation, it must be 
assumed that the bacteria themselves, by their property of producing inflam- 
mation, give rise to the severe, mostly fatal affections. However, we have 
observed a number of cases in which, in spite of septic fever and of the fact 
that the other clinical phenomena pointed to sepsis (such as the gradually 
decreasing power of the heart, the loss of appetite, emaciation, the frequent 
implication of the sensorium) neither purulent foci in the body nor strepto- 
cocci in the blood could be determined, therefore, death appeared to be due 
to a pure septemia. These were mostly cases in which stubborn and severe 
otitis media complicated the disease (but without sinus thrombosis or other 
local infection of neighboring organs). Observations of this kind require 
further bacteriological study. 

The changes in the slcin in scarlatina require further pathologies-anatom- 
ical study. The investigations up to the present do not favor a simple " vaso- 
motor " hyperemia, such as is produced by chemical poisons, but they favor 
inflammatory processes. Besides marked hyperemia of the papillary body, 
the vascular nets in the deeper layers of the cutis are greatly dilated and 
markedly filled with blood, and along the smallest veins narrower or broader 
streaks of round cells are noted, which . cannot be looked upon as anything 
else than as emigrated leukocytes. With this, the tissue of the cutis and the 
cells of the rete Malpighi are apparently richer in fluid, as if swollen, this 
may even be noted in hardened preparations. The fine dark points which we 
shall learn to recognize in the description of the eruption, apparently lie in 
the deeper layers of the cutis (third venous net of Spalteholz), 2 whereas the 
general redness may be ascribed to the papillary body. 

SYMPTOMS 

Our description shall represent the picture of an ordinary, medium severe 
attack of scarlatina. It corresponds to a certain type which this acute 
exanthem possesses, although at the bedside deviations from this model are in 
the majority. 

i Jahrbuch fur Kinderheilkunde, Bd. liii, Heft 5. 

2 " Die Vertheilung der Blutgefasse in der Haut." Arch. f. Anat. u. Physiol., 1893. 



680 SCARLET FEVER, SCARLATINA 

In rare cases indistinct phenomena, general disturbance in health, often 
chilliness and the like, may precede the disease for a few days and even for 
a week, which may be looked upon as symptoms of the period of incubation. 
Usually, however, the disease begins abruptly with severe symptoms, so that 
the chronology of the affection may be accurately determined by the hour. 
The child returns from school in complete health, a quarter of an hour later 
vomiting occurs and at once high fever appears. Or it has gone to school 
quite well and there has an attack of nausea, vomiting appears and the dis- 
ease begins. 

The most frequent symptom at the onset is vomiting, according to the 
time at which the last meal has preceded, either remains of nourishment or 
of mucous fluid, or sometimes even bile-stained masses, are brought up. In 
younger children diarrhea is readily added and then lasts for a day or two. 
Even in nurslings, vomiting and diarrhea are the earliest s} r mptoms. 

In cases of medium severity the vomiting may be repeated several times 
during the first hours of the disease and then cease. Immediately following 
this a general febrile condition appears. In older children, it may be intro- 
duced by a true chill, also in younger ones (rarely) although not as an initial 
symptom ; also, inside of the first few hours or first two days, general convul- 
sions occur, which are not always of unfavorable prognosis. A general feeling 
of malaise, headache (also pain in the limbs), lassitude, irritability, pains in 
the abdomen always rapidly follow. Somewhat later, from twelve to twenty- 
four hours after the onset the child complains of its throat, of pain in deglu- 
tition. In adults, on the contrary, the pain in the throat is frequently the 
first symptom. 

In practice, not infrequently, there is an opportunity of examining the 
child shortly after the initial vomiting. It is always found with marked 
fever, but not always is this high at the onset, but varies between 102.2° F. 
and 103.1° F., but, occasionally, even in moderate cases, the temperature 
rises at once to 101° F. to 105° F. (in the rectum). The child assumes the 
recumbent posture itself, and now a febrile condition is noted which lasts 
from eight to ten days. Even during the first night, febrile unrest, mild 
delirium appear, while during the day the child is apathetic, sleepy, com- 
plains of thirst, burning and pain in the throat, the speech assumes a muffled, 
throaty character. 

Examination of the oral cavity shows a tongue with a white coating, the 
filiform papillae are somewhat reddened and the palatine mucous membrane, 
with a quite sharp line of demarcation toward the hard palate, is markedly 
reddened, showing distinct small macula?, the tonsils are swollen and upon 
their deep reddened surface, not infrequently, reddish, yellowish flakes or 
stria? may already be noted. 

The face sometimes appears bloated, in some cases transversely over the 
nose a saddle-like redness is noted, which coalesces with the fever redness 
of the cheeks, whereas the surroundings of the mouth and chin are almost 
unnaturally sharply demarcated by a conspicuous pallor. 



SYMPTOMS 681 

In the course of the first day or in the first half of the second day the 
characteristic cutaneous eruption appears, usually first upon the trunk, neck, 
chest or back, also in the gluteal region and then, gradually, in the course 
of two days, distributes itself to the extremities. The characteristics of this 
eruption consist in two peculiarities: At the onset it consists of small points 
distinctly separated from one another, which in the course of hours or days 
coalesce, forming a uniform connected mass of a red appearance and, secondly, 
at the onset it is of a delicate red, rapidly or also slowly, even in the course 
of several days, assuming a saturated, burning, flaming, fire-red appearance 
which, therefore, justifies the name of scarlet fever. In all cases that are at 
all developed, this general redness, no matter how intense and flaming it 
becomes, attains its development from separated punctiform areas in so far 
as in the general redness, upon accurate observation, small still darker flakes 
may be recognized, especially if by means of slight pressure upon the skin the 
blood is forced away. Primarily the redness upon decreasing pressure always 
appears first in the original red areas. 

Therefore, upon the neck, on the chest, upon the back, upon a delicate 
white skin, there are first noted delicate rose-red punctiform, from a millet 
seed to a pin head in size, particularly round, areas situated close together: 
At a distance a uniform color is presented, and. only upon close observation 
can the individual points be discerned. Soon the entire trunk appears to be 
covered and now, at the end of the second or the beginning of the third day, 
upon the inner surface of the arms, the thighs, soon also taking in the outer 
surface, reaching to the fingers and toes, the same fine redness is noted. The 
skin at first feels smooth, but with increasing intensity of the redness it 
becomes uneven, coarse, something like shagreen leather. The face frequently 
remains entirely free or only signs of the fine red points are noted upon 
the temples, the dorsum of the nose or on the outer surface of the cheeks. 
The region about the mouth and chin invariably remains free. With each 
succeeding half day the red points coalesce more and more and become darker, 
upon the third, fourth, sometimes only upon the fifth day, the skin from the 
throat to the feet shows a condition as if the patient were covered by a scarlet 
mantle which closely envelops the entire body. In the inguinal region, at 
the elbow, and at the knee joint, upon the buttocks, upon the inner surface 
of the thighs, the eruption is usually particularly intense, often showing a 
bluish-red shade. It is not infrequent, even in cases running a normal course, 
that in these previously mentioned areas the original red points show a hemor- 
rhagic tendency and are then particularly noticeable. 

In not a few cases, particularly upon the abdomen, but even upon the 
lateral aspect of the thorax, upon the back, upon the lower legs, the dorsum 
of the hands and feet, over these original spots there appear vesicles the size 
of a millet seed, filled with a transparent fluid, which later becomes opaque; 
these are called miliaria, which after a few days dry and form scales. The 
contents of these vesicles show an alkaline reaction, therefore, do not 
consist of the secretion of the sweat glands alone. This form of the eruption 



682 SCARLET FEVER, SCARLATINA 

* 

is called scarlatina miliaris, and its appearance is not considered of unfavor- 
able prognosis; in fact, most cases of scarlatina miliaris run a favorable 
course. 

Opposed to this — but even this again has exceptions — is another deviation 
of the exanthem. Upon the third or fourth day in the occasionally slightly 
uneven, but not particularly raised, eruption, nodules and papules the size 
of a lentil seed, usually of a deeply stained color, are noted to appear, which 
are situated at some distance from one another and sometimes produce great 
itching. In those cases in which the rasli has a limited distribution these 
papules may end the general redness and then show an appearance which 
simulates urticaria. This form of the exanthem is seen much more frequently 
in the severer infections. 

Upon the dorsum of the hands and feet the skin occasionally swells and 
becomes glistening, sometimes almost resembling erysipelas. 

A peculiar condition is noted in the fully developed exanthem if the 
finger nail is passed over the red surface, in the entire extent over which 
the nail has passed a white streak of varying intensity is noted (apparently 
due to vaso-motor spasm) which only slowly disappears (raie blanche of the 
French). 

After the greatest intensity has been reached the eruption remains at its 
acme for half a day or longer, then it begins to fade and disappears at the 
end of the first week or the beginning of the second, frequently slight exacer- 
bations being noted in the interval, these usually occurring toward evening. 
Even before the fading is completed the epidermis begins to peel in many 
areas, first, usually, upon the neck, and this desquamation continues often 
for many weeks, even in convalescence. Upon the neck, upon the chest, and 
in the inguinal region, this desquamation occurs in small flakes or plaques, 
from the size of the head of a pin to that of a lentil; they are of a white 
glistening appearance. Upon the buttocks, the thighs, the hands, and feet, 
however, large lamella?, and entire casts of the fingers, or the hands, which 
may renew themselves several times, may be shed. Finally, after a pro- 
longed period of desquamation, the patient enters upon convalescence with a 
renewed skin. 

Occasionally, in this rapid transformation process of the skin, an improve- 
ment in chronic difficulties occurs: Thus, in a case of intense desquamation, 
I once saw numerous warts ' covering both hands of a seven-year-old girl dis- 
appear without leaving a trace. 

Hand in hand with the development of the exanthem the fever proceeds. 
Simultaneously, or even earlier, often even upon the second or third day it 
reaches its acme, the absolute height of which in ordinary cases may be quite 
high, reaching 105° F. or even higher. Usually in a favorable course it does 
not long remain at this height but soon declines, however, not to fall suddenly 
and rapidly but quite gradually and slowly, so that in the course of a few 
days, falling a little each da} r , normal ranges are reached. Characteristic of 
an undisturbed defervescence is the fact that after the temperature has begun 



SYMPTOMS 



683 



to decline no increased rises are noted over the previous evening or morning 
temperatures, whereas in the course of a day the variation between morning 
and evening still remains. The decline of the fever may be likened to a 
staircase which gradually leads downward. 

The following temperature charts (Figs. 26 and 27) are examples of 
simple, uncomplicated scarlatina (rectal temperatures). In the first instance 
the acme was reached rath- 
er late, the defervescence 
being somewhat more 
marked, in the second case 
the acme is noted on the 
second day, the deferves- 
cence being slow and grad- 
ual. Both cases entered 
upon an undisturbed con- 
valescence without compli- 
cations. 

The pulse in scarlatina 
shows peculiarities in be- 
ing very rapid, greater in 

proportion to the height of the temperature and age of the patient than in 
other diseases. This is also true of the uncomplicated cases and it cannot 
even be said that this symptom is more markedly developed in the severer 
infections. In children from five to six years of age, in the first few days, 
even in mild cases with a rectal temperature of 103° F., from 150 to 170 pulse 



Day of 

Disease 12 3 4 5 6 


7 8 9 10 11 12 


r\ A 


Cent. 
J\ 40° 


102 2° J- 


V l \ 


100.4° 


V t 38 




^ 



Fig. 26. 



-Temperature Chart of Simple Uncompli- 
cated Scarlatina. 



Day of 

Disease 1 2 3 4 5 G 7 8 


9 10 11 12 13 14 15 1G 


Fahr. 


Cent. 
40° 


A A A 

102 2" ^J- V ±\ h 




V 




100.4 


v v s^,» 



Fig. 27. — Temperature Chart of Simple Uncomplicated Scarlatina. 



beats per minute, with a temperature of 102° F., 132 per minute, with a 
temperature of 100.5° F., 124 per minute, etc. In a girl aged seven (medium 
severe case), I found, with a temperature of 101° F., 150 beats per minute. 
With higher temperatures, pulse beats of nearly 200 per minute can be 
counted (for example, in a girl aged five with a temperature of 104° F.), 
without the prognosis necessarily being unfavorable. Nor does the pulse 
rise much higher in the very severe, fatal cases with excessive high tempera- 



684 SCARLET FEVER, SCARLATINA 

tures. In a boy aged five, with a temperature of 107.8° F. I noted 196 beats 
per minute. In a case which terminated fatally in a girl aged two, with a 
temperature of 104° F., 204 beats per minute. From this symptom it may 
be quite properly concluded that the scarlatinal poison, more decidedly than 
other infectious products, has a direct action upon the cardiac nerves which 
increase the heart beat. The condition of the pulse in the first days is some- 
times rapid, usually, however, it is soft, not dicrotic. Some sphygmographic 
tracings appear to favor the view that the vasomotors of the peripheral 
vessels are in a certain spasmodic condition, which is also indicated by the 
previously-described " white streak." While the exanthem is reaching its full 
development, the inflammatory affection of the pharynx and the oral cavity 
increases. The tonsils become more swollen, the muco-purulent or fibrinous 
flaky deposits upon their surfaces become distinct, but if they were previously 
present, they now increase and enlarge, the lymph glands at the angle of the 
lower jaw r enlarge and become painful, the tongue loses its w T hite coating and 
the superficial layer is denuded of its epithelium so that the tongue looks red 
and smooth, but the papillae stand out prominently above the surface like red 
warts. If the child protrudes the tip of the tongue between the lips it resem- 
bles a strawberry. A tendency to dryness of the tongue readily occurs upon 
the days when high fever is present. 

With the fading of the eruption and the onset of defervescence the mucous 
membrane affection improves, the yellow spots up©n the tonsils disappear; 
the tonsils are less swollen, the glands decline in size, the tongue regains its 
normal epithelial covering. 

Other decided deviations on the part of the internal organs are not noted 
during the acme of simple scarlatina. The respiratory apparatus is hardly 
affected, at most there may be a slight tracheo-bronchitis. The urine shows 
the characters of febrile urine, it is scant, high colored and, with an intense 
fever, may show small amounts of albumin and some few hyaline casts; this 
disappears as the fever declines. A slight increase in diacetic acid is often 
noted, the diazo-reaction is negative. The spleen i^ very commonly enlarged, 
which may be shown by percussion but may also be noted upon palpation. 

Anorexia is present during the entire course of the fever, but there is 
great thirst. After the preliminary diarrhea the bowels are usually consti- 
pated. With defervescence and a decline in the eruption, there is a return 
of the normal epithelial coating of the tongue, appetite returns, and the 
digestive apparatus begins to functionate normally. 

Toward the middle of the second week the pathological disturbances have 
almost disappeared, only the skin which has been deeply affected still requires 
a longer time to regenerate itself and to return to its normal condition. 

Strength and subjective well being usually return rapidly. Only the im- 
possibility to foresee the later implication of the kidney influences the careful 
physician, even in these cases, to keep the patient in bed at least till the end 
of the third week and to watch him carefully. 



VARIATIONS FROM THE COMMON TYPE G85 



VARIATIONS FROM THE COMMON TYPE 

AVe shall now devote our attention to the manifold deviations from the 
just described simple course, a review of them being only possible in that the 
individual course is viewed particularly in regard to the organic disturbances 
which become prominent. Xaturally, it must not be forgotten that in each 
special case these deviations are not always so distinctly separated from one 
another as they are in text-book descriptions, the disturbances commonly 
combining, crossing or following one another. 

In scarlatina, which quite properly is so much feared, we also note mild 
and very mild affections. In such cases all symptoms of the disease are but 
slightly developed and of a very benign character. At the onset vomiting 
and headache may be present but the pharyngeal affection is only noted by 
slight swelling and reddening, the fever rises to a moderate height for but 
a short time and may sometimes show a purely afebrile character, in other 
cases only subfebrile rises occur, the temperature only rising to 101.5° F. 
and rapidly declining, the fever may even sometimes be absent entirely. The 
eruption consists in a uniform reddening of a pale rose color, distributed over 
the entire body, which may in individual areas, upon the neck, upon the 
buttocks, show a slightly raised character or tin's may be absent entirely: or 
the eruption may only be found in individual areas, for example, upon the 
groins, at the flexures of the knee, upon the neck or upon the back, being 
even fleeting here or remaining for several clays. The diagnosis in these cases 
can only be made with certainty upon a careful observation of the entire body 
and only then by the aid of such knowledge as that other children in the 
house have been attacked in a well developed manner or in the presence of an 
epidemic. Sometimes the eruption is well marked, but only upon one part 
of the body, for example upon the legs, at other times days pass until the rash 
distributes itself from one part of the body to another. 

The rudimentary cases must not be placed in the same category with these 
mild cases. These at the onset may appear quite mild and many of them even 
remain so, but very frequently in the wake of these apparently harmless dis- 
turbances is a late renal affection. The rudimentary character is shown in 
that the infection appears in the form of an angina frequently severe, and 
accompanied by fever, and without any eruption. Especially adults, but also 
older and younger children, for example, also those that have previously had 
an attack of scarlatina and have been exposed anew to a marked family 
endemic are not infrequently attacked in this manner. There is marked fever, 
often also vomiting and headache, a pharyngeal inflammation, with enlarge- 
ment of the tonsils and the adjacent lymph glands, often with flaky deposits 
lasting for some days and then rapidly disappearing and healing without 
serious consequences, so that the patients appear cured in the course of a 
few days. Frequently the sharply defined border of the dusky, sometimes even 
flaky, redness about the hard palate shows the true character of the affection. 



686 SCARLET FEVER, SCARLATINA 

at other times attention is directed to the condition b}' an unusual implica- 
tion of the nasal mucous membrane, in which there is thin mucoid corrosive 
fluid which collects about the openings of the nose and the upper lip, pro- 
ducing excoriation; often even these symptoms are absent in the clinical 
picture and it is thought that an ordinary tonsillitis is present, provided no 
new unquestioned cases of scarlatina are brought about by such cases or unless 
an edema develops two or three weeks later and shows the true nature of this 
angina. 

Compared to the interesting pictures of the disease which we have just de- 
scribed, the affection shows itself sometimes in a dreadful, almost demoniacal 
form, when it appears as a so-called scarlatina fulminans, scarlatina gravis- 
sima, intoxication form of scarlatina. Almost like lightning, or like a poi- 
soned arrow, in the midst of blooming health, and in the course of a few 
hours, destruction has been wrought by this property of the scarlatinal poi- 
son, which, in common with some other infections (variola, cholera, bubonic 
plague, etc.), and in some epidemics, is characterized by a great number of 
such rapidly fatal cases. In the severest cases the affection up to the time of 
death lasts from thirty to thirty-six hours. Such cases are fortunately very 
rare; I have only seen two or three among many hundreds of cases. The 
severest injury to the nervous system on the one hand, to the heart on the 
other, often without the appearance of the usual characteristic symptoms, 
destroys life. The following observation is an example : 

Girl aged three and a half years, taken ill with vomiting, in the afternoon of 
December 6, 1875. An evening temperature of 102.6° F., pulse 176. December 7th, 
early in the morning, a temperature of 104.9° F., pulse 218, unconscious at noon. At 
2.30 in the afternoon I saw the child. There was complete coma, pallor and wide and 
unreacting pupils. Upon the body an erythema, no characteristic eruption was noted 
( a brother aged eight simultaneously had a characteristic scarlatina ) . Temperature 
108° F., pulse could not be felt, 196 cardiac contractions. A bath at 68° F. for fifteen 
minutes, with ice water affusions, followed by enveloping in woolen covers was ordered. 
Pupils then reacted somewhat but no signs of returning consciousness. Four o'clock 
in the afternoon, temperature 102.9° F., 108 cardiac contractions. Bath at 77° F., 
followed by almost no reaction; soon afterward death occurred. The entire affection 
lasted twenty-eight hours. 

By far the greatest number of the cases of this group last longer, from 
three to four days, until death occurs which, according to my experience, 
cannot be prevented. ■ The onset of the disease may be fulminant, character- 
ized by very severe and almost continuous vomiting and retching, or also by 
spasms, and even general convulsions. At other times these serious symp- 
toms only develop upon the second day after a moderate onset; above all, they 
consist of an unusually severe implication on the part of the nervous system. 
Sometimes violent, at other times quiet but continued delirium or maniacal 
irritability introduce the drama and rapidly lead to a profound implication 
of the sensorium, to complete bewilderment or deep coma. The face usually 
assumes a peculiar disturbed, frightened expression. This severe implication 
is usually paired with great restlessness of the motor organ; it appears as if 



VARIATIONS FROM THE COMMON TYPE 687 

an internal fear compels the little sufferer to a continuous change of posi- 
tion of the body and thus the patient is often found with the head hanging- 
out of bed, lying across the bed or in a complete inverted position in the bed. 
Very frequently the respiration is loud, resembling that of a person who has 
run for a long time or it may be that form of respiration which occurs in 
diabetic coma, deep, long-drawn and difficult. The appearance of the rash 
varies greatly. The face is sometimes peculiarly streaked, red, white, pale 
about the mouth, sometimes there are red streaks upon the cheek, and temple, 
sometimes dark disseminated, papulous eruptions may be seen, the face as 
well as the trunk showing a bluish marbling, and only toward the end of life 
does the rash become more distinct. In other cases, on the contrary, a very 
rapidly developing intense eruption is noted, which very soon takes on a deep, 
dark, cyanotic discoloration. In one of my recent cases, in a child aged one 
year and a half the entire skin of the body was covered by dark blue maculae, 
varying in size from a lentil to a silver dollar, which did not disappear upon 
pressure, while only in some few areas were they smaller, showing a more 
elevated appearance. The child was not placed in the scarlet fever division 
of the hospital as its disease was looked upon as a " septic " skin erup- 
tion. The pharynx is sometimes but slightly affected, at other times 
it is markedly implicated, reddened and swollen. The tongue is d.vj, red, 
fuliginous, the breath distributes a sweet smell resembling acetone. In the 
urine a marked diazo-reaction is present, occasionally moderate amounts of 
albumin and hyalin casts may be noted. The urine as well as the feces 
are voided involuntarily; the stools show for the most part a diarrheic 
character. 

The fever is high from the onset or at least from the second day on, not 
infrequently it is excessive. The pulse becomes exceedingly rapid, often being 
irregular. Acute dilatation may be recognized in the heart, and the weakness 
of this organ is the immediate cause of a rapid, fatal termination. In another 
series of cases this does not occur in such a stormy manner as has just been 
described, but death takes place unexpectedly by a rapidly appearing cardiac 
collapse. In such cases there is also high fever, delirium, marked eruption, 
rapid pulse, but in the interval the child shows freer moments, takes nourish- 
ment, being less excitable and more quiet, until suddenly, with high fever, 
occasionally with slight twitchings (once I saw these twitchings occurring 
bilaterally), death comes on quickly. In cases of this kind the total duration 
of the disease is from three to four days. 

In a third category of these severest cases, the infection lasts longer, up 
to six, seven, even to eight or nine days. To the severe general symptoms 
an extremely high-graded implication of the pharyngeal region is superadded. 
Whereas the nervous system is not so markedly affected, so that consciousness 
toward the end of life, even though disturbed, is not completely lost, there 
rapidly occur difficulties in deglutition and respiration, a true "narrowing of 
the fauces/' due to a high-graded swelling of the entire naso-pharyngeal ring. 
Speech is throaty, can scarcely be understood, respiration is stertorous, the 



688 



SCARLET FEVER. SCARLATINA 



head and neck are held stiff, somewhat posteriorly, the entire neck being rigid 
and immovable. Inspection of the throat shows marked swelling at the base 
of the tongue, the tonsils, of the palatine arches and of the uvula, so that these 
structures appear as if joined, and from the fourth or the fifth day on a 
board-like swelling in the region of both angles of the jaw is added which dis- 
tributes itself rapidly around the inferior maxilla and, meeting the swelling 

coming from the opposite side, 
takes in the entire upper region 
of the throat so that these struc- 
tures appear to be girdled with 
rigid armor, rendering movement 
entirely impossible. This swelling 
is due to a phlegmonous condition 
of the connective tissue of the 
throat in the region of the rapidly 
infected and gangrenous lymph 
glands coming from the pharynx. 
If children remain alive up to 
the beginning of the second week 
marked destruction of the organs 
of the throat, which have been 
subject to this diphtheroid condition, will take place and a flooding of the 
entire blood with streptococci with subsequent pyemic suppuration will de- 
velop. A severe, usually continuous, fever, accompanies this process which 
already belongs to the realm of sepsis. The course of such a case is shown 
by the accompanying temperature curve (Fig. 28). 

These forms of the disease, with their rapidly developing buboes about 
the throat, with subsequent phlegmons and widely distributed tissue necrosis 
may readily be designated as simulating the plague. 



Day of 
Disease 


1 


2 


■■$ 


4 


5 


6 


7 


8 


9 


10 




Fahr. 
105.8° 

104.0° 

102.2° 

100.4° 




































f- 




+ 


Cent. 
41° 

40° 

39° 

38* 


\ 




r 


^ 


\ 




J 


^ 


V 




J 


\ 




A 


<J 


r 


J 


r 








s/ 




p< 


* 


V 
lil 


:e 


fo 


■11 


o 


f S 


ea 


:1a 


ti 


V 

la 


w 


th 
















Oe 


1 


ie; 
tr 


1-t 

ep 


)U 


JO- 

•o< 


S3, 

CI 


P 

s 


lie 

ie] 


en 


:° 


nc 


us 

















































Fig. 28. — Temperature Chart of Pestlike 
Form of Scarlatina with Buboes. 



They form the transition to scarlatinal diphtheroid, the second variety of 
severe scarlatinal infection, the more or less prominent predominance of the 
condition giving the character to the scarlatinal epidemic. In this variety, 
disease of the pharyngeal structures and the adjacent organs is most pro- 
nounced in the pathologic process and only by this means do secondary general 
disturbances occur which again may bring about a fatal change in the disease, 
but then no longer being part of the original scarlatinal process but to a 
great extent being of a septic nature. 

The pathologico-anatomical process which in this variety of scarlatinal 
infection attacks the pharyngeal organs has been accurately described pre- 
viously in this article. It need only be repeated that it consists in a peculiar 
combination of inflammation and necrosis, in which the latter must infallibly 
follow the former provided a coagulable exudate is deposited in the tissues of 
the affected organ. This occurs in scarlatinal diphtheroid to a greater or to 
a lesser extent. 



VARIATIONS FROM THE COMMON TYPE 



689 



The disease frequently is accompanied from the onset with high fever and 
marked swelling of the pharyngeal parts, as well as superficial deposits upon 
the mucous membrane of the palatine tonsils. In other cases the first days 
may run a course without any symptoms pointing to the threatening danger. 
Besides the other symptoms which may be completely or irregularly developed, 
thus, the fever, the nervous disturbances, the cutaneous eruption, there is 
usually found a sharply circumscribed swelling and reddening of the mucous 
membrane of the palate and pharynx. With the full development of the 
eruption the fever begins to decline from its acme. A regular course appears 
to occur. The first sign that denotes disturbance is usually the condition of 
the temperature. Upon the morning of the fourth or fifth day of the disease 
the gradual drop in the temperature which has already begun is interrupted; 
either the morning remission or the evening exacerbation is greater than the 
day previously and from this time on the regular declining course of the fever 
ceases and the course becomes atypical. As the observation of this slight 
alteration in the temperature course is important, in prognosis as well as in 
treatment, I shall show some examples of this course in the temperature, with 
corresponding remarks. The underscored portions in the temperature curve 
indicate the change in the course of the disease. 

The observation of the pharyngeal parts at this time does not always 
indicate the region in which the danger threatens, for which the temperature 
gives the signal of alarm; especially in little children, in whom the investi- 
gation of the pharyngeal areas is often difficult there is noted for the most 
part only a conspicuous increased formation of a thick tough mucus which 





A.Oskar 6 years 


B.Clara 6 years 


Or. Franz 3 years 


G. Ernst 5 years 




Day of 
Disease 


1 


2 


3 


4 


5 


6 


1 


2 


3 


4 


5 


6 


1 


2 


3 


4 


5 


6 


1 


2 


3 


4 


5 


G 




Fahr. 
105.8° 

104.0° 
102.2° 
1U0A° 












A 


1 














































































Cent. 

41° 

40° 
39° 

38° 








/ 


\ 


t 


v 


V 


^ 






























/ 


-V 


\ 
































A 






J 


I / 


; 








V 










f 


\ 


/ 


V 




•*■ 


\ 


V 






h 






\ 


/ 


1 








/ 


A 


»•. 


*v 


/ 


V 


' 






/ 










































/ 














* 










J 


v 




















R 


eco 

c 


fi 

-J 




a 


:tt 

e 


c 

11 


less 
J 


^ ; k 


s 


I 

_ 


)e 


it 


l 


>n tl 


e 


12 


h 


D 


K 




)e 


it 


i 


>n 


tl 


e 


20 


b 


D 


iy 




: 


)e 


ath 


ox 


1 1 


it 


2 


s1 


D 


1} 





Fig. 29. — Ixitial Rise of Temperature ix Four Cares of Scarlatixa. 



covers all parts, rendering an opinion regarding the nature of the beginning 
changes even more difficult. In older patients it may be noted how the coat- 
ing upon the tonsils increases, or also in cases in which no superficial deposits 
are present it may be seen how a slight yellowish or grayish-yellow discolora- 
tion occurs in the tonsillar tumor, especially in its lateral aspect, particularly 
in the spaces between the palatine arches; or a hemorrhagic swelling of the 
45 



690 SCARLET FEVER, SCARLATINA 

lower portion of the uvula, of the anterior surface of the palatine arch or 
similar conditions. Simultaneously with this a flow from the nose occurs, 
which does not, especially at first, produce anxiety. A thin, stale or even' 
somewhat decomposed, yellowish-red fluid comes from one or hoth nasal open- 
ings and leads usually quite rapidly to an excoriation of the nasal openings or 
the upper lip. These excoriated areas show a lardy or dirty gray deposit. 
At the angle of the mouth small fissures appear (partly due to the forcible 
opening of the mouth, but even without this), which soon show a similar 
coating. Finally, there is added swelling of the lymph glands, first those of 
the angle of the lower jaw then also the neighboring groups, in the upper 
triangle of the throat, under the sterno-cleido-mastoid. These increase rap- 
idly from day to day, from the size of a bean to the size of a hazelnut, or 
even attaining the size of a pigeon egg; they are painful to the touch. At 
first they are movable, soon, however, they appear in the underlying tissues, 
forming conglomerations of tumors. 

Now the difficulty increases from day to day. The tongue becomes dry, 
the fever hovers around decided heights, the pharyngeal parts swell more 
markedly or — in the severest cases, those previously mentioned as resembling 
bubonic plague — in a brief period, in a night, they change into a leather- 
like, brownish-yellow dead tissue. In ordinary cases the discoloration pri- 
marily attacks circumscribed areas and rapidly produces tissue necrosis. 
After the end of the first week a part of the tonsil, . the lower por- 
tion of the uvula or also a portion of the velum of the palate may be 
destroyed and be changed into an ulcer covered with necrotic masses. This 
is not only the case in visible parts but is not even infrequent upon the poste- 
rior surface of the velum of the palate. The diphtheroid has established itself 
about the choana, about the arch of the pharynx and is the cause of the 
ichorous flow from the nose. After existing for scarcely a week, as the result 
of these diphtheroid destructions, it may be noted sometimes even suddenly 
that a deep hole has formed in the anterior palatine arch, often circular or 
punched-out in appearance, in the depth of which the partly destroyed tonsil 
is found; at other times there is a deep fissure in the velum of the palate, 
which under some circumstances causes a fall of the entire palate upon the 
uvula, or upon the base of the tongue, at other times a separation of the uvula 
and the like. These destructions are always accompanied by a particularly 
profuse excretion of mucus from all the diphtheroid portions of the neigh- 
boring mucous glands. In some cases there is added a severe abscess inflam- 
mation of the entire oral mucous membrane accompanied by marked sali- 
vation; deep ulcers form upon the tongue, the lips swell enormously, are 
traversed by bloody fissures and disfigure the entire face. 

Not infrequently does the diphtheroid inflammation attack the larynx, 
forming a rigid infiltrate of the ventricular bands and of the subglottal 
mucous membrane folds as well as numerous small discontinued desquamated 
deposits upon the surface of the mucous membrane. Both together then lead 
to stenosis of the larynx, which clinically is similar to true laryngeal diph- 



VARIATIONS FROM THE COMMON TYPE 691 

theria, giving rise to the symptoms of croup and rendering tracheotomy 
necessary, which, in fact, only rarely avails to save the threatened life. If 
then the function of the velum of the palate is hindered, either by rigid swell- 
ing or by destruction, a condition resembling paralysis appears ; there is nasal 
speech, regurgitation of fluid through the nose, symptoms which readily lead 
the inexperienced physician to the erroneous conclusion that he is dealing 
with true diphtheria. 

Although the local signs may be well developed and distributed, they but 
very rarely cause the tragical termination of these cases. It rarely occurs that 
the destruction invades the tissue so deeply that a larger pharyngeal artery 
is eroded and a fatal hemorrhage occurs ; this is an extraordinarily rare devel- 
opment. In the main, even these deep losses of substance heal with surpris- 
ing rapidity if the organism is able to recover from the disease. The indi- 
vidual is particularly threatened by way of the glands and the blood vessels. 

In the chapter upon pathological anatomy it was explicitly stated that 
this danger consists in the entrance of streptococci which produce inflamma- 
tion and suppuration in the tissues and in the blood. There the various ways 
were described by which this occurs. The organism of the scarlet fever 
patient responds to this invasion in numerous regions by the appearance of 
hemorrhagic and purulent inflammations, the extent and number of which 
depend upon the nature of the entrance and possibly also upon the intensity 
of the original scarlatinal fever process. 

A benign consequence of streptococcus infection consists in a more or less 
extended swelling of the lymphatics of the lower jaw and neck and the tran- 
sition in one or the other gland into simple suppuration and abscess forma- 
tion. Unilaterally or bilaterally upon the neck a circumscribed painful 
swelling appears, sometimes at the angle of the lower jaw, at other times 
lower down and more posteriorly, occasionally upon the sterno-cleido-mastoid, 
and in these cases it is usually combined with a transitory stiffness of the head 
and neck, and with a remittent febrile temperature. Without rupturing, the 
tumor may recede after existing for weeks, or very frequently in the first, 
in the second or even in the third week, a deep-seated and later more super- 
ficial fluctuation appears, the skin becomes red, tumefies and ruptures in 
case it has not been incised previously, and pus is discharged. 

Frequently suppuration does not occur but dry necrosis takes place. One 
gland after another enlarges, with continued high temperature, until tumors 
the size of a walnut and larger develop; the surrounding connective tissue 
becomes tough, and in the entire region there is a board-like infiltration, indi- 
vidual areas of the skin are discolored, becoming dark blue and then showing 
gangrenous decomposition; if these parts are incised with the hope of finding 
pus, a dry, almost cheesy tissue of a grayish-red color is met with that shows 
the distinct characteristics of gangrenous substance. It is fortunate if by 
means of a profuse suppuration in the surrounding tissues these dead masses 
are desquamated and discharged. Much more commonly even these show 
a gangrenous decomposition and upon both sides of the neck after prolonged 



692 SCARLET FEVER, SCARLATINA 

fever, markedly distributed, deep losses of substance are noted, the carotid 
being seen to pulsate at the base, and in some instances even the wall of 
this vessel has become eroded and a fatal hemorrhage has terminated life; 
however, death usually takes place without this complication, due to the 
exhausting fever and the septic consumption. Frequently the local diph- 
theroid process takes place in the ears as well as in the nose and in the con- 
junctiva and before death relieves the child both eyes may be totally destroyed 
due to the inflammatory necrosis. 

Again, in other cases the infection runs its course without such conspicu- 
ous symptoms but is no less threatening. Slowly the purulent infiltration 
creeps along the trachea, in the glands, and the neighboring connective tissue, 
invading deeply and, finding entrance into the thoracic space, it leads to puru- 
lent mediastinitis, to which often weeks later a large ichorous empyema or 
a pericarditis is added. To what tortuous tracts this latter fatal affection may 
lead I have observed twice, in cases in which a purulent meningitis caused the 
fatal termination, that this had not originated from the nose or the ears but 
was primarily of a spinal nature, thence having ascended to the brain. In the 
previously described manner a posterior mediastinitis had taken place, from 
which a purulent right-sided pleuritis had originated, and thence the suppura- 
tion passed through the intercostal nerves, and traversed the intervertebral 
foramen, thus reaching the spinal cord cavity. 

Probably some general purulent cases of peritonitis which are met with in 
connection with scarlet fever develop in the manner indicated here, by con- 
tinuity. But just here it may be mentioned that occasionally also appendicitis 
may precede. I have noted the appearance of this disease a few times in the 
course of scarlatina; a similar relation of conditions has lately been noted 
between purulent typhlitis (appendicitis) with purulent inflammations of the 
tonsils, the same genetic connection existing. 

If these serious changes which have just been described regarding purulent 
infection remain local and its distribution is limited to the neighboring lymph 
glands and lymph spaces in the connective tissue, in another series of cases it 
arises by means of metastasis in areas quite removed from one another, pro- 
vided streptococci in larger numbers find their way into the blood. The great 
number of these organisms in the blood can always be shown by bacteriologic 
investigation. In connection with Bahrdt I published the first case of this 
kind in which the mere microscopic examination of the blood and of the prod- 
ucts of the purulent metastasis, showed the general proliferation of the 
microbes through the entire organism. The way in which this rupture occurs 
has been directly shown in individual cases to be due to an original diphtheroid 
affection of the pharyngeal passages, a septic, inflamed and thrombosed vein 
being near by in which a septic decomposition of the clogged coagula has 
occurred. Here by means of continued, usually high, fever, in which, how- 
ever, chills occur in all possible parts of the body, in the subcutaneous tissue, 
in the muscles, the kidneys and in other internal organs, smaller and larger 
abscesses develop: a true pyemia. The joints and serous membranes, espe- 



VARIATIONS FROM THE COMMON TYPE 



693 



daily the pericardium, are by far most 
frequently affected by this scarlatinal pye- 
mia. The joints in large numbers, the 
small as well as the large joints, are then 
subject to purulent infection. The knee 
joints, the elbow joints, the wrist joints, 
on one or both sides, especially also fre- 
quently the finger joints, enlarge so that 
there is marked pain upon touch, the pa- 
tients who are usually almost comatose in 
this condition manifest the pain by loud 
cries. The cutaneous covering is reddened 
in a wide area above and below, swelling 
in a manner sometimes resembling ery- 
sipelas. It is terrible to see how such 
joints are completely destroyed in a few 
days, so that upon careful examination 
with careful movement, the completely de- 
stroyed cartilage is felt detached from the 
bared ends of the bones. 

But even with these catastrophes the 
list of lesions which may arise from scar- 
latinal diphtheroid is not yet exhausted. 
The distribution of the local mucous 
membrane disease has not yet been men- 
tioned or but briefly indicated, which still 
contains a quiver full of dangerous ar- 
rows : disease of the ear. This is a very 
frequent complication of scarlatina. In 
the hospital I noted it in 27.-1 per cent, 
of all admitted cases (393 patients in the 
years 1894 to 1897). In the usual man- 
ner, by way of the Eustachian tube, the 
severe mucous membrane affection main- 
tains its character in the pharyngeal cav- 
ity, showing a tendency to inflammatory 
necrosis of the mucous membrane and 
neighboring bones. The milder forms of 
otitis media lead to simple perforation 
of the tympanic membrane, whether this 
occurs naturally or artificially, termin- 
ating in slow recovery with profuse sup- 
puration. Very often, however, this does 
not terminate the condition; in spite of 
sufficient opportunity for the pus to flow 





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694 SCARLET FEVER, SCARLATINA 

off, the inflammatory necrotic affection continues into the antrum and to the 
cells of the mastoid process, in which the osseous tissue itself is implicated 
and changed into an ichorous necrotic inflammation. From here the infec- 
tious process finds its way to the sinus or to the meninges. And in this man- 
ner either a general blood affection, a pyemia, is produced, or, by absorption 
of the poison from the ear, a fatal septemia or a purulent meningitis leads 
to the lethal termination. 

The scarlatinal otitis just described, in its severer forms, is always accom- 
panied by marked and tenacious fever, which even with proper treatment 
may last for weeks and lead to a severe consumption of bodily strength, so 
that then only slightly increased disturbance is sufficient to entirely obliterate 
the remaining feeble strength. Persistent unrest at night, insomnia, delir- 
ium, usually a high grade of anorexia, diarrhea and bronchitis belong to the 
complications which increase the ear difficulty. 

The temperature curve (Fig. 30) on page 693 shows a picture of the long- 
continued condition occurring in the child as the result of diphtheroid and 
severe otitis, until finally recovery took place. 

In this case the appearance of the exanthem was delayed, appearing upon the 
fourth day and being but little characterized; only upon the eleventh day was there 
marked swelling and redness of the tonsils with a deposit upon their surface. With 
a rise of temperature, upon the fourteenth day of the disease the otitis media became 
prominent. Upon the sixteenth day a high grade of edema was present in the region 
of the right mastoid process, and in operation upon the seventeenth day the bone was 
found discolored to a great extent and necrotic, the antrum being filled with granula- 
tions and discharging ichorous pus. Slowly and gradually the desquamation of the 
necrotic osseous tissue took place. 

Upon the twenty-second day of the disease there was a sudden exacerbation of the 
condition with a severe chill. Now the sinus transversus was exposed; puncture, how- 
ever, did not show the presence of pus. The internal jugular vein was tied with a 
hook upon the right side to prevent the entrance of septic products from the ichor- 
ous ear. 

In spite of the continuation of the irregular septic fever until the fifth week of the 
disease, gradual improvement occurred in the osseous wound. Finally, complete recov- 
ery was still further interrupted by a spasmodic attack upon the forty-second and forty- 
fifth days of the disease which, however, left no deleterious consequences. Ultimately 
hearing in the right ear returned and was quite good. 

At the end of the twelfth week the little patient visited me in my office. The wound 
in the ear had healed. 

In cases of this kind the help of a skillful ear specialist is required, as 
delay and temporizing is not in place in these severe forms of scarlatinal otitis, 
in which every day may bring about a serious condition, but the diagnosis 
must be followed in these cases by an immediate life-saving operation. It 
is a mistake to dread " interference with the natural process of healing," for 
this is as good as impossible or represents but an exceptionally fortunate 
termination. Usually the case runs on as in the following instance when 
an operation was attempted : 

Boy aged thirteen and one half years was taken ill upon December 13th, with a 
medium severe attack of scarlet fever. Defervescence occurred about December 20th, 



VARIATIONS FROM THE COMMON TYPE 695 

and upon December 21st there was an exacerbation and the development of otitis media. 
In spite of the appearance of the tympanic membrane and the auditory canal denoting 
trouble, the posterior wall swelling out and even granulation formations occurring, 
neither the family physician nor the specialist who was called in consultation could 
conclude to operate upon the mastoid process. In the beginning of January the fever 
became higher, strength declined more and more and now another ear specialist was 
called in, who immediately opened the mastoid process and found the entire bone com- 
pletely softened, and all of its cells filled with pus. Following operation, there was 
general improvement and decline of fever. But even upon January 3d, there was severe 
pain in the splenic region, followed by a septic peritonitis, jaundice, and death upon 
January 5th. 

Probably even before the final opening of the pyogenic focus, sinus thrombosis and 
septic splenic infarct had occurred. 

But even without such fulminant phenomena having preceded, we are 
often surprised by the consequences of an insidious and treacherous disease 
of the tympanic cavity and of the antrum. 

I recently saw an instance of this kind. Upon July 2d, a girl aged twelve years 
was attacked by scarlet fever, which appeared to run a mild course, so that only on 
account of the great anxiety of the parents regular visits were continued up to the 
third week. Upon July 19th, an otitis media began to develop, paracentesis being per- 
formed a few days later. Upon July 25th, the mastoid process was moderately painful, 
but as no fever had developed it was, nevertheless, advised to open the bone. The 
operation took place upon July 27th, and great quantities of thick yellow pus were 
discharged. Upon July 28th, pain in the back, and in the course of the day headache, 
eleven o'clock in the evening temperature of 104° F., pulse 160. During the next few 
hours great unrest, rigidity of the muscles of the neck; death upon July 29th, at a 
quarter past one o'clock in the morning. 

In this instance, in a very rapid manner and in an originally very mild case of 
inflammation of the middle ear, a fulminant meningitis occurred. 

In several instances in which there was an otitis media with an appar- 
ently good flow of pus, a continued fever was present which could not be 
explained and in which it was advised to open the mastoid process, in spite 
of the fact that no swelling of its coverings could be determined and only 
slight pain upon pressure and the swelling of a lymph gland lying behind the 
ear pointed to its implication. Invariably, pus and granulations were found 
in the cells. The fever disappeared and recovery occurred. In cases of this 
kind, naturally, the opinion of a specialist who has been called in consulta- 
tion must be considered and he must be supported if he decides in favor of 
an operation. Instances like those just described rather incline us to take 
upon ourselves the reproach of polypragmaty than to be guilty of omitting 
an operation which perhaps might save life. 

Scarlatinal Rheumatism. — Much less serious are those irregularities in 
the course of scarlatina, due to swelling of the joints, which is usually desig- 
nated by the name of scarlatinal rheumatism. This must not be confounded 
with the previously-mentioned joint affection which almost always is of an 
unfavorable prognosis. 

Scarlatinal rheumatism is not a very frequent complication. I noted the 



696 SCARLET FEVER, SCARLATINA 

condition 29 times in 358 cases, therefore, in 8 per cent. In my Children's 
Hospital it was found in 6.7 per cent, of the cases. This proportion allows 
of the conclusion that the affection is not in immediate connection with the 
scarlatinal poison but is due to special auxiliary causes. The pathogenesis is 
not accurately understood, only this much is certain that this multiple joint 
affection occurs in no other infectious disease as frequently as in scarlatina 
(acute articular rheumatism naturally excepted). 

Clinically, the affection resembles acute articular rheumatism in many 
respects, but in the main it is more transient in character and of briefer 
duration than acute polyarthritis. 

In rare cases the condition may be noted upon the first day of the dis- 
ease; not only as a general muscular pain, but with distinct localization, for 
example, in the feet. As a rule, it occurs during the second half of the first 
or the first half of the second week, therefore, in the period between the fifth 
and twelfth days of the disease. The large as well as the small joints of 
the extremities are affected. The vertebra, the jaw, etc., I have never seen 
implicated. Scarlatinal rheumatism appears to have a special preference for 
the wrist joints, and also the finger joints are not infrequently attacked. But 
the legs are by no means spared, the knee joint, the ankle joint, sometimes the 
joints of the toes and even the hip joints are attacked. Occasionally the 
affection is only limited to a pair of joints, for example, both knee joints, 
both wrist joints. Sometimes the affection wanders from one place to another, 
similar to the condition in primary articular rheumatism. 

The local symptoms are quite similar to those in acute rheumatic fever. 
Occasionally there is no swelling or redness in the region of the joints, and 
pain upon pressure and pain upon spontaneous movements — but this may 
occur with great severity — show the implication of the joints, sometimes, how- 
ever, there is marked periarticular swelling and redness or a distinct effusion 
into the joint may be noted. Occasionally I found that the entire skin of 
the feet or the hands was edematous, and once I observed, during an un- 
usually prolonged attack of scarlatinal rheumatism lasting ten days, the 
appearance of a general (vaso-motor ?) anasarca without any signs of a 
nephritis. The cutaneous edema disappeared simultaneously with the rheu- 
matism. 

The duration of the complication is almost always brief, limited to a few 
days (three to five). In how far the antirheumatic treatment which was 
employed by me may have caused this cannot be determined with certainty. 
Some few cases that I saw during the early periods of my practice, before 
the action of salicylic acid was discovered, ran a similar brief course to those 
that were treated. 

A remarkable fact is that the heart is implicated in a like manner to 
that occurring in acute articular rheumatism, regardless of whether arthritic 
pains appear or not. 

As a rule, these endocarditic processes are of a benign nature. They 
must be entirely separated from malignant affections occurring by way of 



VARIATIONS FROM THE COMMON TYPE 697 

metastasis (similar to the analogous joint affection), particularly from those 
due to the diphtheroid affection of the pharyngeal organs and cervical lym- 
phatics which preferably attacks the pericardium, but may also implicate the 
endocardium, causing a rapid destruction of the valves of the heart and lead- 
ing to septic infarcts in various internal organs. Another form of cardiac 
disease which was previously mentioned in the description of scarlatina gra- 
vissima and which we shall mention again in the description of scarlatinal 
nephritis, consists in an intense (toxic) damage of the heart muscle, the 
myocardium, showing itself by a dilated cardiac weakness, occasionally in 
the form of sudden cardiac death. From these affections also the rheumatic, 
or rather rheumatoid, form of scarlatinal endocarditis, which we must consider 
now is to be entirely separated. It develops occasionally in the same period 
with the rheumatoid joint affection, therefore, between the first and second 
weeks of the disease. Sometimes the signs of the affection are only noted after 
complete disappearance of the eruption, improvement of the scarlatinal affec- 
tion and the return of subjective well being, during an apparent period of 
convalescence. Subjective symptoms are almost entirely absent and the com- 
plications cannot be discovered without auscultation; by this means, however, 
most markedly at or near the apex, but sometimes even most plainly at the 
base, a brief or longer soft murmur, synchronous with the ventricular con- 
traction will be noted. A little later perhaps also a moderate distribution of 
cardiac dulness and a slight accentuation of the second pulmonary sound may 
be demonstrated. The patient who is still in bed does not complain and per- 
haps only a somewhat marked pallor of the face is conspicuous. Sometimes 
endocarditis is combined with pericarditis, and then with the corresponding 
objective phenomena decided symptoms appear. 

It will be noted in not a few such cases that these signs disappear entirely, 
and in those cases in which there is an opportunity for prolonged continued 
observation the patients recover completely without signs relating to the heart. 
To a certain extent it always remains questionable whether there is an endo- 
carditic process or whether only so-called accidental (functional) murmurs 
are present. But, on the other hand, from these rheumatoid, scarlatinal endo- 
cardites, unquestionably, valve lesions arise. jSTot infrequently is there an 
opportunity to note this, as the cases of cardiac murmurs, which are not very 
rare, that have positively developed during the course of scarlatina, are almost 
always found to disappear. I am, however, in possession of the facts of a case in 
which from a previously intact heart during an attack of scarlatinal rheuma- 
tism, the appearance of a murmur was observed and the gradual development 
of a typical mitral insufficiency could be followed step by step. Thus the scar- 
latinal infection in this direction is also treacherous, not being immediately 
dangerous to life but permanently damaging health. That in scarlatinal 
endocarditis the musculature of the heart (or the nerve-cells of the heart?) 
is not spared may be concluded from this, that during the existence of a cardiac 
murmur very frequently a more or less great irregularity of the pulse is 
observed. This is by no means so rare, even though there be no opportunity 



698 SCARLET FEVER, SCARLATINA 

of demonstrating an endocardial complication occurring particularly in the 
stage of convalescence, often only in the sixth or seventh week and even later 
and then disappearing. This appears to occur particularly in those cases in 
which the affection is prolonged by nephritis. 

The so-called scarlatinal typhoid, the relations of which to the disease are 
not yet quite clear, but which for the most part represents a benign and by no 
means frequent deviation from the normal course : A fever accompanied by 
moderate symptoms of depression and occasionally of marked disturbances on 
the part of the digestive organs and lasting for a long time without demon- 
strable local disturbances. Even this conception shows that not every febrile 
sequel of scarlatina that cannot be easily explained can be designated by the 
above name. And in every fever of this kind it is our first duty to search for 
the point at which resorption of material which may produce fever is pos- 
sible. Such areas are numerous enough in the case of scarlatina. In my 
experience, especially the posterior pharyngeal wall and the posterior nares as 
well as the nasopharyngeal space should be considered. If there be seen — 
even although a previously present pharyngeal diphtheroid has disappeared — 
upon the posterior pharyngeal wall any decided muco-purulent secretion, a 
roughening, a superficial erosion or granulation of the mucous membrane, the 
possibility that the fever is due to this cause must not be overlooked and the 
result of a suitable local treatment often enough shows the correctness of this 
assumption. 

The second point of origin of the septic post-scarlatinal fever is in the 
lymph glands. If these are found hard upon one side or both sides and large 
and sensitive, the fever may be due to them even if they do not always sup- 
purate. A third point of origin may be traced to one or the other region of the 
middle ear, which has already been mentioned above. 

But, besides these septic post-scarlatinal fevers, there are individual cases 
in which even the most exact and careful investigation will not reveal the 
source of the fever and in which the temperature curve does not at all show 
the intermittent or remittent character of resorption fever, but shows moreover 
a certain similarity to typhoid fever. As an example, the following temper- 
ature chart in which this fever occurred between the eleventh and twenty-third 
days of the disease, is shown (Fig, 31). 

A boy aged two and a half years was attacked, upon April 19th, with vomiting and 
fever, simultaneously with hoarseness and cough, in the midst of complete health; 
upon the second day of the disease, upon the arms and legs as well as upon the buttocks, 
there was at first a non-characteristic, later, a decided, eruption with marked redness 
of the pharyngeal areas. Upon the seventh day of the disease desquamation occurred, 
which continued into the fourth week, the scales consisting of large and long lamellae 
of the epidermis, from the gluteal region as well as from the ribs. The cutaneous red- 
ness as well as the angina had disappeared in the second week, only at the angles of the 
mouth fissures formed with a lardaceous coating which required a long time for healing. 
No lymphatic enlargement or otitis developed. The kidneys remained intact. For the 
continued fever from the tenth day on there was no explanation. A dry bronchitis 
occurred, which continued for a long time, the abdomen from the fourteenth day of the 
disease became tympanitic, was painful to pressure, and diarrheic stools of a greenish- 



VARIATIONS FROM THE COMMON" TYPE 



699 



yellow color appeared. The spleen was not palpable. The child was irritable, now and 
then vomiting recurring, and with these symptoms the affection continued even longer 
than the time shown in the temperature curve. After the twenty-third day of the 
disease the temperature was no longer regularly taken: toward the middle of May 
recovery gradually occurred. 

Apparently the process which produced the fever in this case developed 
in the digestive organs. It has been previously mentioned that under the 
influence of a scarlatinal affection, the mucous membrane not only of the naso- 
pharyngeal space, but under some circumstances that of the entire intestinal 
tract shows hyperplastic swelling. It might be supposed that in such cases 
resembling a mild enteric course this deleterious influence of the scarlatinal 
poison affects the adenoid tissue which is so profusely present in the intestinal 
tract, as well as the mucous membrane, and thus leads to a condition of the 




Fig. 31. — Temperature Chart of Scarlatixal Nephritis. 



digestive organs which resembles that brought about by the pathogenic agent 
of enteric fever. This cannot be determined with certainty as cases of this 
kind are not subject to anatomical investigation. In concrete cases, one point 
is still to be observed. Occasionally at the onset of enteric fever an eruption 
occurs which may closely resemble the exanthem of scarlatina. In such genu- 
ine cases of enteric fever with pseudoscarlatina, the appearance of the rash 
(roseola), the proof of typhoid bacilli and agglutination are the points of 
support for the correct diagnosis. 

A rare deviation of the regular course of the disease is shown by the 
relapse. By this we do not understand an increase of the redness upon the 
skin, which is frequently observed, causing the eruption to become plainer, 
which shows itself by a new rise in temperature, but the return of all of the 
symptoms of scarlatina, or at least of the eruption, after a complete cure of 
the primary affection. 

This relapse which resembles the condition arising in enteric fever occurs 
in individual cases. 

A boy aged seven, who suffered from a mild attack of scarlet fever from June 24th 
to July 8th, after he had been out of bed showed upon July 19th a decided swelling 
of the cervical lymph glands; following this, upon July 21st, with moderate fever, a 



700 SCARLET FEVER, SCARLATINA 

new exanthem occurred, which in individual areas consisted of large macula and in 
others of small macula, having partly a measly appearance. Upon July 25th, the fever 
disappeared, swelling of the glands declined, and the eruption could no longer be noted. 
In another instance a boy aged four was attacked upon June 30th with scarlatina, 
with quite an intense diphtheroid and lymphadenitis. During the period of desquama- 
tion, in which the angina improved, upon July 13th, with renewed but brief fever, a 
fresh eruption occurred upon the right forearm and right thigh. 

In the course of a gland abscess during the existence of a nephritis I saw 
upon the fourteenth, and also upon the twenty-third, day of the disease a 
relapse and appearance of the exanthem with high fever. These relapses do 
not appear to be serious. 

If the patient has resisted or escaped all of the described dangers which 
may occur in the course of the first two weeks of scarlatina, he has not yet 
escaped all of the dangers of one of the most treacherous infections ; for, unex- 
pectedly, after he appears to have been on the high road to recovery, often 
without any warning, an affection of the kidneys may attack him, which we 
meet with in many other affections, but in no other does it occur so frequently 
or so severely or take on such a substantive character as in the case of scar- 
latina. Scarlatinal nephritis may be looked upon as the prototype of infec- 
tious nephritis. 

Scarlatinal Nephritis. — It is by no means a necessary consequence of the 
infection, as only a part of those affected, and at that a small part, shows this 
complication. In fifteen years in my private practice I observed 36 cases of 
scarlatinal nephritis in 358 cases of scarlatina, therefore, almost exactly 10 
per cent. In 393 cases in the course of four } r ears, in the Charite in Berlin, 
77 cases showed a nephritis, that is about 20 per cent. (19.6 per cent.). This 
difference, however, is not so great as it appears, as in private practice there 
are many more mild cases than are met with in the hospitals. The epidemics 
of individual years vary greatly, climate and perhaps racial characteristics 
appear to play a certain etiological role. Johannessen reports of some Nor- 
wegian observer that he had 90 per cent, of renal affections in scarlet fever 
patients. But even in Norway the statistics of those physicians that have had 
a large experience do not rise above 20 per cent. 

This is a remarkable difference from those complications which develop 
from the point of entrance of the supposed poison in the pharyngeal organs. 
Here in 60 per cent, of the hospital patients we found a diphtheroid mucous 
membrane inflammation. 

What condition of the total disease brings about the renal inflammation is 
still unknown. Evidently it cannot be sought for in the severity of the infec- 
tion at the onset, if we may judge from the intensity of the symptoms. For in 
quite a number of cases of nephritis, among them particularly the severest 
(for example, in my practice of 5 fatal cases, 4!), a mild, sometimes scarcely 
noticeable preliminary affection, with slight fever, fully developed eruption and 
mild angina precedes the complication. 

It has already been mentioned above, that particularly the rudimentary 



VARIATIONS FROM THE COMMON TYPE 701 

cases often only become dangerous from the renal complication. And the 
period of the appearance of the renal affection in the course of scarlatina is 
against the view that it is an immediate action of the contagion. On the 
other hand, unquestionably, the development of scarlatinal nephritis from 
accidental external influences, possibly refrigeration, leaving bed too early, 
errors in diet and the like, may be rejected, for the development of nephritis 
cannot be prevented by the most careful nursing and diet and it affects those 
that are kept in bed constantly and patients that are only nourished with milk, 1 
to the same extent as those not so carefully treated. The influence of errors 
in regime are not to be entirely denied, but these must only be looked upon as 
auxiliary causes and do not by any means play the chief part, as, for example, 
in the development of pulmonary complications in measles. Especially the 
so-frequent appearance at a distinct period of the course stamps nephritis as 
an affection belonging to the scarlatina process. It is a late action of the 
infection. That it occurs at all is perhaps favored by a special sensitiveness 
of the organs or loss of resistance. The occurrence of such relationships of 
individual cell groups to certain poisons, particularly also to the group of 
parasite toxins, has been sufficiently determined with certainty by the new 
experimental etiology. Clinically, this view is favored by the circumstance that 
not so very rarely a distinct family predisposition to scarlatinal nephritis is 
met with in so far as often two or more children (I myself saw four) of the 
same family simultaneously show nephritis after scarlatina. It can scarcely be 
doubted that the kidney forms one of the excretory organs of the abnormal 
products, the symptoms appearing after the infection and in this manner the 
" haptophorous " cell groups of the organ may become diseased. 

A fact which at first glance is peculiar has been mentioned several times, 
that this renal inflammation occurs during the period in which the rest of the 
process, the throat affection, the rash and the possible joint implication have 
disappeared. The first period of the symptoms which denote a renal affec- 
tion appears at the end of the second or in the third week. Among my 36 
cases, which for a great part I observed from the onset of the disease, the 
affection began seventeen times between the twelfth and fifteenth, ten times 
between the seventeenth and nineteenth days of the entire process. In the 
other cases the period was uncertain, or the onset of the affection occurred in 
a later period. Exceptionally, the renal disease may even occur several weeks 
after an intervening period has preceded. Lately I noted this complication 
in the thirty-eighth day of the affection in a girl aged two years and nine 
months. 2 

i That is not always an advantage. Exclusive milk diet is apt to cause indigestion, 
indicanuria, and subsequent renal irritation. It is about time we should change that 
exclusive milk diet into a mixed milk and cereal diet. It takes a long time before 
the results of biochemical studies are utilized in practice. — Editoe. 

2 In my experience nephritis may be looked for on the ninth or tenth day, and 
onward, up to the twenty-third, after which it is rarely observed. I have seen it to 
appear on the fifty-fourth day of a scarlatina in a girl of seven years exhibiting a very 
slow desquamation with no other bad symptoms. — Editor, 



702 SCARLET FEVER, SCARLATINA 

The child was taken ill on January 1st, and upon January 5th was sent to the 
Charite\ The course of the disease was not particularly severe, being combined with 
a mild diphtheroid. The urine, constantly examined, was still free from albumin upon 
February 4th. Upon February 7th, a mild hemorrhagic nephritis occurred, which 
began to disappear upon March 3d. 

This paradoxical condition, which is analogous to certain symptoms of 
late diphtheria, as well as to some infectious diseases of very long incubation, 
was explained by some physicians in that they assumed that the renal affec- 
tion existed from the onset of the disease and only produced symptoms late 
in the course of the malady. It is true that with high fever, in the first week 
albuminuria and casts occur in the urine; but after defervescence this disap- 
pears completely. In dozens of cases which were carefully examined for this 
sign, various authors, especially Thomas, found that the composition of the 
urine for days and weeks after the primary febrile albuminuria was again 
completely normal before scarlatinal nephritis quite suddenly appeared. From 
my own experience, I may throughout confirm the views of Thomas. Accord- 
ing to my investigations, as well as those of other authors, for example Sbren- 
sen, the anatomical changes in the kidneys of scarlet fever patients that perish 
in the first week are entirely absent or but very insignificant. It is not easy 
to comprehend how especially the last named author refers the development 
of nephritis to the first period of the entire process. This view nowadays is 
shared by but very few physicians. 

In a pathologico-anatomical, as well as in a clinical respect, scarlatinal 
nephritis shows a character which naturally is also peculiar to other infectious 
renal inflammations, but which is particularly prominent in scarlatina, and at 
least in the recent cases and in those that are at all well developed it is never 
absent : This is the hemorrhagic character of the pathological process. In the 
anatomical examination this is well defined to the careful observer, even if 
not always macroscopically still microscopically, naturally, provided that the 
organ is not hardened in alcohol, which destroys the hemoglobin. Sorensen 
found in 15 carefully examined cases of scarlatinal nephritis numerous, 
mostly hemorrhagic casts in the uriniferous tubules, and in 11 cases several 
times, " yellowish masses " in the capsular space. Kauf mann describes acute 
hemorrhagic change in the kidney due to scarlatina. I have examined various 
cases of scarlatina carefully and agree with those observers that have found at 
the onset of the disease, especially in the grave cases that succumb early, a 
marked hyperemia of the organ but as yet no signs of inflammatory changes. 
Only during the period in which the children succumb to the consequences of 
nephritis (cardiac asthenia and dropsy, especially pulmonary edema or ure- 
mia) does the kidney show distinct signs of hemorrhagic inflammation, above 
all, in the glomeruli. The accompanying figure (technically a not very com- 
plete reproduction of a photogram) gives an example of such a hemorrhagic 
glomerulitis. 

The thick opaque capillary loops, rich in nuclei are seen, from which 
intense hemorrhage (b) has occurred. These fill a part of the capsular space, 



VARIATIONS FROM THE COMMON TYPE 



703 



the epithelium of which has proliferated. The convoluted uriniferous tubules 
near the glomeruli from which hemorrhage has occurred are filled with the 
exuded blood (cc). But we are not dealing here with a simple collection of 
red (and corresponding white) blood corpuscles in the lumen of the canal, but 
its entire contents, usually including the epithelium, have been moulded 
together in a coagulated mass, in which no longer any nuclei of the epithelia 
are discernible but only a homogeneous or slightly granular mass is noted, 
in which red blood corpuscles, usually of a small diameter, may be seen. 
Here, therefore, the blood which has exuded from the glomeruli as it appeared, 
produced a toxic 
action of the epi- 
thelia. In such 
areas, by means of 
methods which al- 
low the fact to ap- 
pear, always larger 
or smaller globules 
of fat partly still 
in the form of epi- 
thelium may be 
noted. In the loops 
of the uriniferous 
tubules I have never 
seen such hem- 
orrhagic coaguli. 
Hemorrhages, how- 
ever — in so far as 
we are justified in 
concluding from po- 
sition and form of 
the epithelium — oc- 
cur also in the 
spaces between the 

renal tubules ; here, however, they are not combined with such epithelial necro- 
ses but simply lie in the lumen, which could occur in no other manner but by 
diapedesis. In the collective tubules, finally, clogging by hyaline casts is 
found and here also without deeper implication of the epithelium, the nucleus 
of which is still retained. Only here and there a desquamation of the entire 
epithelial cylinder from the basic membrane of the tubule is shown. The 
massive clogging of the straight canals (here and there also of the loop canals) 
has a further consequence: that of urinary stasis in the entire area of the 
affected collective tubules. Thus the convoluted canals of the labyrinth, which 
are not affected in the previously described manner are found dilated to a great 
extent, their lumen large, their epithelium (otherwise unaltered) pressed 
against the wall. This is also true of the intercalary portion as well as of the 




Fig. 32. — Microscopic Section of Kidney in Scarlatinal, 
Nephritis. 



704 SCARLET FEVER, SCARLATINA 

convoluted tubules. The damage of the active part of the kidney consists, 

therefore, in a disturbance of the normal function of the glomeruli (especially 
in the excretion of water), secondly in a destruction of a part of the secreting 
epithelium of the labyrinthine part of the canals, and thirdly in stasis of the 
secretion in the remaining part. This is the process in the pure, severe cases 
(for example in a case dying after nine days of anuria). 

In the milder cases, the two deleterious effects upon the parenchyma of 
the kidney are of but slight extent, whereas the hemorrhages from the glomer- 
uli may even be considerable. In the formation of casts in the uriniferous 
tubules, it will depend particularly upon their density and adherence as to 
whether the consequences will be severe or mild. 

From the observation of these findings (fresh frozen sections of kidney 
hardened in formalin) it will be seen that in this form of nephritis the 
primary damage occurs in the vascular arborization, therefore, in the inter- 
stitial part of the glandular organ (this, for example, is not so marked in the 
diphtheritic kidney). Most noticeable in the glomeruli, and first studied by 
Klebs and afterward by numerous other investigators, this pathological change 
has led to the designation of the scarlatinal kidney as a glomerular nephritis. 
But this does not mean that only the glomeruli are implicated. Although I 
cannot recognize the periarteritis described by Fischl in the small arteries, the 
circumstance that»the capillary net which surrounds the labyrinthine tubules 
allows blood to exude proves that even there the endothelial covering of the 
capillary tube is diseased. This may be more marked in the secretive portions 
of the capillary system than in the nutritive area. 

That in consequence of the damage to the capillary wall, not only the previ- 
ously described hemorrhages but also in more or less numerous areas, collec- 
tions of leukocytes appear around the vessels, is readily comprehended. In 
the recent cases of pure scarlatinal nephritis, this finding plays no great role. 
Particularly dense is this noted in areas in the boundary layer in the vicinity 
of the curved arterial twigs, around the glomeruli and upon the surface of the 
kidney. 

If the scarlatinal nephritis has lasted for weeks or months previous to the 
anatomical examination, the interstitial conglomerations of cells may reach 
high grades and may lead to an extended change in the parench)mia, necrotic 
areas, connective tissue proliferation and contraction, producing an entirely 
different picture. But even in these cases the interstitial inflammation will 
be prominent. Septic renal disease which occurs in connection with severe 
diphtheroid, in a restricted sense differs in its anatomical appearance from the 
scarlatinal, more closely resembling other septic processes. 

In fatal cases in which scarlatinal nephritis enters upon a chronic condi- 
tion, it usually takes the course of a very slow contracted kidney, which requires 
at least a few years for its development. 

The comparatively slight mortality from scarlatinal nephritis, in spite of 
the frequent threatening symptoms, denotes in the main that the damage to 
the kidney is not too severe. Of 36 cases observed by me, 5 died, a mortality 



VARIATIONS FROM THE COMMON TYPE 705 

of 14 per cent. In the hospital, during the years 1894 to 1898 the mortality 
from renal inflammation amounted to 26 per cent. 

Clinically, the appearance of nephritis in the scarlatinal picture in quite 
a number of cases is not characterized by subjective symptoms. The parents 
notice a disturbance of convalescence in their child, either by a swelling of 
its face or by the odor or composition of the urine. More than once have I 
been called by a mother to see her child, with the remark that its urine 
resembled hers during the menstrual period. Otherwise the child was quite 
well. With these symptoms the inflammation of the kidney not rarely runs 
its course from beginning to end. 

In other cases the disease begins with new general symptoms. The tem- 
perature rises, either in the form of a single daily rise to a moderate or even 
to a decided height (over 104° F. even to 105.5° F.), with chills, burning or 
sweating, or the fever continues for several days, even lasting for weeks, show- 
ing a remittent course. The cause of these variations in the reaction is not 
known. The intensity of the nephritis and of the fever do not always run par- 
allel. 

Then vomiting is often frequent, which may be repeated many times dur- 
ing the first days, to this there is added headache and. restless sleep; anorexia 
is also present. 

The pulse often rises with the fever, but, on the other hand, abnormal 
slowing and arrhythmia are observed. Thus in a boy aged seven years, upon 
the sixth day of a febrile nephritis (terminating in recovery), I counted 64 
regular beats per minute, in another case, in a boy aged eleven years, a nephri- 
tis began upon the nineteenth day of the scarlatina, the pulse was from 96 to 
100 per minute; in the second week of the renal inflammation it fell to 60 to 
66, rising again as recovery advanced. 

Slight swelling due to dropsy of the subcutaneous cellular tissue can 
always be observed upon careful examination; above all, a slight edema of the 
face and a brief pitting upon pressure with the finger upon the tibial surface 
and upon the sternum. Often dropsy is much more marked, especially in the 
legs and upon the buttocks, being combined with a watery transudation in the 
abdominal cavity, in the pleura and in the pericardium. 

If the urine has not been examined previously the symptoms just men- 
tioned lead the physician to an examination and now the great change that 
has occurred is discovered. In place of a light yellow or light orange colored, 
clear, profuse urine, its characteristics a few days previously, a turbid red- 
dish-brown or dark red, opaque fluid is noted, which shortly after standing 
deposits a more or less dark cloudy sediment. If the daily quantity is meas- 
ured it is found to be decreased, for example, from the previous 1,000 to 1,200 
c.c. its volume may be decreased to 600, 500, or even less. In keeping with 
this, the specific gravity is raised. An examination of the filtered fluid shows, 
more or less marked contents of albumin (2, 3, up to 7 per thousand and 
more) and the dark color is shown to be due to an admixture of blood, the 
coloring matter being determined by the guaiac test or by Heller's sediment 
46 



70G SCARLET FEVER, SCARLATINA 

test. If the admixture of blood is not very marked, the urine is light red in 
color, sometimes resembling the washings from beef. If held to the light it is 
shown to have a greenish tinge. 

An examination of the sediment shows numerous erythrocytes; they are 
often conspicuously small and not, infrequent^, besides a small undamaged 
erythrocyte, or an erythrocyte appearing as if it had been dissolved,, a brown 
granular detritus may be noted even in freshly voided urine. From this it 
must be concluded that not rarely also in the kidney, perhaps even in the 
renal vessels, a decomposition of the red blood cells has occurred. I noted once 
during the period in which nephritis usually occurs a severe hemoglobinuria 
with a rapidly following fatal termination. 

Besides blood corpuscles, there are found in the sediment various hyaline 
casts of varying character, large and small, long and short, smooth and 
uneven; often red blood corpuscles are found enclosed in the casts or are 
adherent to them. Some casts are purely epithelial; some are impregnated 
by urate salts, others carry finer or coarser globules of fat, again others con- 
tain leukocytes. Finally, waxy casts are also seen. In recent cases, leukocytes 
are not very predominant, renal epithelium is not scant. Cells with fat 
granules are quite rare; I once saw them on the first day of a nephritis in a 
boy aged seven years ; the course of the affection was mild. 

Besides these changes, which are due to the anatomical disturbance in the 
kidney, in the course of the last few years it has been attempted to determine 
the diminution in functional activity somewhat more accurately, in that the 
effort has been made to determine the change of the molecular concentra- 
tion by means of physical examination. The results obtained by cryoscopy 
of the urine up till now are, however, by no means conclusive. The function 
which can be determined by simple measurement, for the present, is the only 
practical one from which we may form an opinion, both in a diagnostic as 
well as in a prognostic respect: the excretion of water. The lower this falls 
the more serious the prognosis. The daily amount of urine, not the albumin 
contents, and certainly not the composition of the sediment, inform us regard- 
ing threatening danger. 

In the mild cases the excretion of urine does not fall below 400 to 600 c.c. 
per day. For a week or two the previously described composition of the urine 
remains the same, the daily quantities become larger, the color lighter, and the 
daily quantity of albumin smaller. Finally, the albumin disappears entirely. 
But the sediment does not disappear at once; even days after no trace of 
albumin can be proven by the most delicate tests, the desquamation of epi- 
thelium and casts still continues. The total duration of the affection is about 
three weeks. The subjective difficulties are always moderate; a certain lassi- 
tude is even shown by the patient that remains in bed and he always shows an 
unusual pallor and swelling of the face, even in the cases in which no marked 
dropsy is present. In fact dropsy may be absent entirely in the mildest cases. 
Gradually as recovery occurs the normal healthy color of the face returns. 

This is different, however, in severe cases. The subjective difficulties are 



VARIATIONS FROM THE COMMON TYPE 707 

greater and very often the patient complains of pains in the renal region 
which are increased by pressure; these pains are otherwise generally localized 
to the abdomen. I have never seen severe attacks of colic due to acute inflam- 
matory changes in the kidney as have been described by Israel. 1 The appetite 
is gone and diarrhea is often present. The pallor is of a high grade, the face 
occasionally appearing waxy pale, almost transparent. 

The diminution in the amount of urine is conspicuous; in a few days the 
excreted amount falls to 150, 100, 50 or even c.c. and this anuria may last 
for days (in a case recently observed nine full days passed before death 
occurred). However, in the urine that is excreted there is sometimes observed 
the paradoxical phenomenon that it contains less of a pathological admixture 
regarding albumin as well as sediment than the previous profuse urine. This 
can hardly be explained in any other, manner than that such a secretion occurs 
from areas of the kidney that are but slightly attacked, the convoluted tubules 
of which are not clogged. The anatomical investigation in the severest cases 
also shows by no means a simultaneous severe affection in all areas of the 
glandular organ. 

Xow, as a rule, but a few days pass before the symptoms of uremia appear. 
Headache and vomiting recur, the child becomes restless, anxious, tosses itself 
about from side to side, crying and moaning; the tongue shows a smeary 
thick coating, the breath has an ammoniacal odor and in the expired air 
ammonia can be demonstrated; appetite has disappeared completely. Fre- 
quent desire to micturate and fecal evacuations occur, but not a drop of 
urine can be pressed out. Gradually this condition of excitement is suc- 
ceeded by somnolence, the child is quite apathetic, with closed eyes; it snores 
and if awakened, rapidly returns to a state of sopor as if under the influence 
of alcohol, or it is even entirely unconscious, and now the picture that has 
become monotonous is varied by the sudden appearance of general spasmodic 
attacks resembling epilepsy. Sometimes this condition is preceded by par- 
tial, even quite monoplegic spasms, for example, in one half of the arm or 
one half of the face, and then only does the major attack, with general tonic- 
clonic spasms, pupillary rigidity, foaming at the mouth and complete uncon- 
sciousness take place. These attacks may succeed one another until a rapid 
fatal exhaustion occurs. All the spasms cease after a number of attacks and 
consciousness returns. Then those about the child are appalled by a new 
phenomenon, the child has lost its sight. The appreciation of light and dark- 
ness may have ceased entirely. This uremic amaurosis is not due to any 
change of the eye-ground but it is to be looked upon as a toxic disturbance 
of function in the light centre of the cerebrum. This is favored by the rapid 
disappearance of this pathologic symptom as well as by the observation that 
the amaurosis before it disappears entirely, sometimes changes into hemi- 
anopsia. 

This convulsive catastrophe sometimes has the appearance of an actual 

i Deutsche med. Wochenschrift, 1902, Nr. 9. 



708 SCARLET FEVER, SCARLATINA 

crisis. Soon after the disappearance of the severe spasms the quiescent urinary 
secretion returns, a highly intense bloody urine is voided in rapidly increasing 
amounts, the blood contents then disappear simultaneously, the other threaten- 
ing symptoms abate and the patient recovers. In some few cases there is added 
to this acute attack a prolonged permanent condition of psychical disturbance, 
a melancholic depression, with renewed spasmodic attacks. This, however, 
occurs almost always only in individuals with a nervous taint. 

Unfortunately, often enough, even during the attack, death occurs. 

The material or the materials which produce this influence of a true 
intoxication upon the cerebrum, giving rise to this symptom-complex, in spite 
of numerous investigations, have not yet been determined with certainty. 
That this intoxication is due to a retention of products which have not been 
excreted can scarcely be doubted. It may, however, be remarked here, that 
the severity of the uremia in all cases is not parallel to the degree of anuria. 
I saw a fatal case of uremia (in severe scarlatinal nephritis), in which the 
spasms, that in a few hours caused death, occurred upon the afternoon of a 
day in which the secretion of urine amounted to 600 c.c. Two days previously, 
however, the uremic headache had already appeared. Just this, in my 
opinion, is in favor of the fact that scarlatinal uremia is not alone due to 
action of the retention of a product of excretion known to us, but to the 
formation of new toxic products, the retention of which in a number of regions 
of the kidney is sufficient to give rise to severe even fatal damage to the 
nervous substance. 

Strauss, 1 in his examinations of the blood of uremia in chronic renal cases, 
appears to have come to a similar conclusion when he says that " the increase 
of the molecular concentration of the blood is an accompanying symptom, not 
the cause of uremia, that the poison which produces uremia is mostly found 
in those persons in whom also other pathologic substances are found in the 
blood in abnormal profuse amounts." But, naturally, uremia is usually to be 
the more feared, the more marked and continued the diminution of the excre- 
tion of water, because in this case the substances which are soluble in water 
remain in the kidneys. 

This condition, parallel with the excretion of water, is shown by a second 
symptom which is a regular accompaniment of severe scarlatinal renal inflam- 
mation : dropsy. 

Although it is not entirely absent in mild cases, this symptom only becomes 
intense when combined with a low excretion of urine. The face, legs and 
arms swell, the abdominal covering becomes markedly edematous, as well as 
the scrotum and penis. At first the swelling is firm, so that the pressure 
of the finger soon disappears, but after a prolonged existence it becomes flaccid 
and soft as in other cases of anasarca. To this must be added the transu- 
date into other parts of the body, ascites, hydrothorax, hydropericardium, and 

i " Die chronischen Nierenentziindungen in ihrer Einwirkung auf die Blutfliissigkeit." 
Berlin, Hirschwald. 1902. 



VARIATIONS FROM THE COMMON TYPE 709 

in some cases very serious pulmonary edema and edema of the glottis. Re- 
garding the development of dropsy, much debate has arisen. It was believed 
that simple retention of water was not sufficient to explain anasarca, there must 
be added especially an alteration of the vascular walls. In fact, I recently 
noted in the skin of a dropsical child inflammatory changes about the cuta- 
neous vessels similar to those noted in recent cases of scarlatina. But whether 
this is necessary, is very questionable. The water that the organism does not 
succeed in excreting must remain somewhere, as the lungs are not able to dis- 
pose of it; but, while it cannot be denied that dropsy may occur with a plen- 
tiful secretion of urine, being absent upon a diminution lasting for any time, 
the latter condition refers to a very few days, and in the former circumstance 
another point must be considered, to which various authors have already called 
attention (for example, Fiirbringer), the importance of which must not be 
undervalued. 

Scarlatinal nephritis also has an effect upon the heart. There are not 
many diseases which, like scarlatinal nephritis, even after a brief existence, 
are capable of bringing about a decided dilatation (and under some circum- 
stances also hypertrophy of both ventricles). This action upon the heart 
muscle not only can be proven at the autopsy, but shows itself by a dissemi- 
nation of cardiac dulness, by the diffusion of the apex beat and the influ- 
ence upon the pulse (at the onset often abnormal slowing, see above, later 
the pulse wave becoming small and low upon increased cardiac action), but 
also by very conspicuous clinical signs denoting a diminished function of the 
heart. Then there develops, often only after a successful recovery from a 
uremic catastrophe, a new series of difficulties of another kind. The child 
again becomes restless, cannot sleep, loses its appetite, begins to complain, 
this time, however, not regarding headache and nausea but of a tightness 
and pressure in the chest, of dyspnea and cardiac anxiety. N"ow the child 
becomes dyspneic without any cause of this symptom being discernible on the 
part of the lungs. The condition is one of cardiac dyspnea. About this time, 
as a rule, dropsy and, later, transudation into the serous cavities begins to 
conspicuously increase. The secretion of urine, however, does not diminish 
markedly and the sediment shows a great tendency to the formation of urates. 
This new increase in dropsy is apparently not only in connection with the dis- 
turbance of the renal function but for a large part it is due to cardiac weak- 
ness. Thus we meet here for the second time (or including endocarditis, the 
third) with a danger which threatens the heart, due to scarlatina. 

These infrequent cases, in which scarlatinal nephritis leads to a marantic 
condition, therefore to a general high-graded dropsy, enormous swelling, 
especially of the scrotum, deathly pallor, complete anorexia, sometimes accom- 
panied by profuse diarrhea, cool and cyanotic extremities, scarcely percep- 
tible pulse, producing a pitiful condition which often drags along for many 
weeks and then, on account of many varieties of complications, bedsores, 
phlegmons, gangrenous erysipelas, pulmonary hypostasis, brings about the 
fatal termination — find their explanation particularly in the severe damage to 



710 SCARLET FEVER, SCARLATINA 

the cardiac power. Naturally, the phenomena of chronic uremia may increase 
the difficulties. But even during the first weeks of a renal inflammation the 
symptoms of decided cardiac asthenia may be intermingled with those of 
uremia. Such cases, in my opinion, always show a very serious prognosis. 
An important sign of this combination is the increase in size and tension of 
the abdomen which may be determined in some anuric patients. This is due 
to a high-graded enlargement of the liver in consequence of stasis, and this 
again is a consequence of the failure in the circulation of the blood. 

The cause of the fatal termination of anuria is not always the nervous 
system. A child that was recently observed by me, in which anuria existed 
nine days, sat in its bed, played with its toys, was restless from time to time, 
but in most respects did not present a condition that would cause an inex- 
perienced person to suspect the terrible danger which existed for the little 
patient. Not a spasm occurred before death, and the mind was clear. 
Finally, in the course of a few hours the symptoms of slight stenotic respi- 
ration appeared (consequent upon edema of the glottis) and then the child 
rapidly succumbed in a severe collapse. In this instance apparently not the 
usual uremic cerebral intoxication, but a cardiac intoxication was the decisive 
cause. 

Finally, the same condition must be assumed, in which the fatal termina- 
tion of severe nephritis is brought about by pulmonary edema; on the other 
hand, the addition of a pulmonary affection is to be looked upon as a dan- 
gerous secondary mixed infection. 

In a case of this kind observed by me, in a boy aged one year and a half, the renal 
inflammation occurred on the thirteenth day of a medium severe scarlatina; upon the 
fourth day after this the secretion of urine fell to 50 c.c. per day and at the end of the 
second it again rose from 50 to 100 c.c. without uremic symptoms appearing. In the 
beginning of the third week, in the decidedly dropsical child, a high irregular fever and 
a pulmonary inflammation occurred, during which the edema almost completely disap- 
peared. At the end of the third week of the nephritis death occurred, being ushered 
in by tracheal rales. The autopsy showed enlarged kidneys, the parenchyma of a 
yellowish-red consistence; hypertrophy of the left ventricle; lobar pneumonia of the 
right lower lobe. 

If all the dangers are considered which threaten the life of a case of scar- 
latina complicated by renal disease, we are actually astonished that the prog- 
nosis in scarlatinal nephritis in general is not so serious as might be supposed 
from the first view of the case, that, moreover, upon the average six-sevenths, 
in many epidemics still more patients, recover from this condition. 

It is true, whether acute nephritis is mild or severe in its onset, in the 
background there still hovers for the apparently convalescent patient a threat- 
ening spectre : the transition of the acute into a subacute and chronic affection. 

Formerly this eventuality was scarcely considered, denied by some physi- 
cians, or at least looked upon as very exceptional. Since convalescents are 
constantly examined and for weeks kept under observation, and the renal 
secretion investigated, we have become convinced that this development is by 
no means so rare, even though the children subjectively and — apart from 



VARIATIONS FROM THE COMMON TYPE 711 

the composition of the urine — objectively, scarcely show disturbances in their 
general health. Often enough, however, in the further course of the affection 
a decided rekindling of the disease interrupts this condition, which then 
takes a similar course, giving rise to dangers like those of the first onset of 
the affection. 

Usually the transition into this permanent condition occurs in the man- 
ner that after the complete disappearance of the dropsy, and of the possible 
uremic symptoms, and after the reappearance of a profuse urinary secretion, 
the chemical examination of the urine shows a permanent excretion, often of 
scant, frequently also of profuse, amounts of albumin. This excretion of 
albumin may often show a distinct orthotic character, i. e., it disappears 
when the patient is in the recumbent posture and reappears as soon as he 
assumes the erect posture. Later it may, however, lose this character. The 
color, weight and amount of the urine often show no decided deviations, at 
most that urine following a period of diminished excretion, this being some- 
times succeeded by decided polyuria; but the microscopic examination of the 
sediment teaches that we are still dealing with a mild hemorrhagic form of 
nephritis. Besides casts of various kinds, granular, hyaline, waxy, also some 
containing blood corpuscles, almost without exception some few red blood 
cells are met with; however, as a rule, many more leukocytes are present; 
finally, almost constantly either few or a large number of fatty granular cells 
are found, sometimes free, sometimes adhering to casts. Not infrequently 
intermittent albuminuria may be noted. 

This continues for weeks. The weeks become months, the months become 
years ; and if albumin were not present in the urine, the children, who usually 
only have a pale color and complain more or less of headache, would hardly 
be considered ill. But the question always arises: What becomes of them? 
This is certain: In favorable cases, even after an existence for years, the 
albuminuria may disappear completely; this usually occurs in the period of 
puberty. A case of this kind occurred in the son of a physician and was 
determined by the father. Secondly, from a nephritis of this sort, within a 
few years or after a decade, a complete typical contracted kidney may arise. 
An instance of the first kind I have observed myself, and of the second 
Dixon Mann gives a very striking example. 1 It can scarcely be doubted that 
not all the cases which continue unimproved in youth finally take the course 
observed by Mann. Thus, we meet here with another danger of scarlatinal 
infection which casts a shadow over the entire future life of the patient who 
is fortunate enough to recover from scarlatina. For although such patients 
during the entire life may show a certain degree of health they hardly ever 
reach old age. 

[Such persons show a remarkable tendency to develop albuminuria (sub- 
acute or acute nephritis) upon exposure to dampness, especially dampness 

i Heubner, " Chronische Nephritis und Albuminuric im Kindesalter." Hirsehwald, 
Berlin, 1897, pp. 54 u. 52. 



712 SCARLET FEVER, SCARLATINA 

associated with cold, or upon the occurrence of any acute disease. I have for 
some years been in the habit of interrogating patients suffering from renal 
disease, in regard to scarlet fever, and in particular post-scarlatinal dropsy in 
their childhood, and have been astonished at the frequency of the association 
of these conditions in individuals who have for many intervening years enjoyed 
excellent health. A much larger proportion of those who develop nephritis 
in adult life give a history of severe scarlatina with or without dropsy in 
childhood than a history of the milder forms. But there are mild forms 
which cause nephritis as a direct sequela, and a chronic form lasting decades, 
ending sometimes in sudden death preceded by a convulsion. — Editor.] 

There are still some complications, which, although not belonging imme- 
diately to the clinical picture of scarlatina, must be considered as they some- 
times influence the entire course of the affection. 

Little has been said regarding an implication of the respiratory organs in 
the affection. The diphtheroid mucous membrane affection of these, even in 
severe cases, does not pass beyond the larynx. The ominous importance of 
hoarseness and the stenosis which appear have already been noted. But occa- 
sionally there is added an intense purulent inflammation of the bronchi and 
lungs which may reach such a degree of severity that this alone is sufficient 
to cause the unfavorable termination. 

Recently, in the clinic, I saw a boy aged five years who showed high fever, while 
the eruption was still at its acme. He succumbed upon the sixth day of the disease, 
showing severe changes in the bronchi and lungs. The palate was hardly red, there was 
only medullary swelling of the lymphatic tissues, neither the tonsils nor the larynx 
being implicated; however, the lower lobes of the lungs upon both sides were of tough 
consistence and of a dirty brownish-red color. Upon section, a bloody edema was noted, 
but air was also present and from all bronchial openings fluid pus escaped. Upon both 
pleura fresh fibrinous deposits. The heart was very relaxed. 

In a second case, in a boy of ten, who died on the fifth day of the disease, there 
was found in the left lower lobe, a disseminated purulent capillary bronchitis, lobular 
infiltration and edema. 

I once saw in a nursling of six months, upon the sixth day of scarlatina, 
the appearance of a severe capillary bronchitis, from which, however, the 
child recovered. 

The bacteriological examination of the bronchial mucus of the cases occur- 
ring in the clinic, in which bronchitis was present, showed the presence of 
streptococci, so that we will not be far wrong if at least in the severe forms 
of bronchopneumonia we regard these cases as due to the aspiration of these 
microbes which play such an important role in the secondary infections in 
scarlet fever. 

The organs of digestion are with comparative rarity affected to any marked 
extent. Sometimes jaundice is noted in scarlet fever; it may be of a catar- 
rhal nature and does not influence the course of the disease in a prominent 



VARIATIONS FROM THE COMMON TYPE 713 

manner. 1 have seen it occur also in septic cases in which, however, it pre- 
sents an ominous sign. 

Severe diarrhea is sometimes met with in septic pharyngeal affections; 
it only occurs in the severe and usually fatal cases, taking place in the last 
few days before death, and is due to an inflammatory swelling of the mucous 
membrane, especially of the large intestine. Here perhaps streptococci are 
also the cause. 

The central nervous system in the case of scarlatina, similar to the other 
acute exanthemata, occasionally presents severe disturbances, which are so 
closely connected with the infectious disease that it is difficult to speak of 
them as mere accidental occurrences. A case recently observed by me is an 
example of this : 

A girl aged eight years was attacked upon November 22, 1900, by diphtheria, which 
was cured by antitoxin treatment. Upon December 2d a new illness appeared which 
at first was supposed to be a serum exanthem, but soon showed itself to be scarlatina 
complicated by severe diphtheroid. Great destruction in the pharynx, numerous lymph 
gland abscesses and nephritis prolonged the disease for over two months. Up to the 
middle of February, 1901, fever was present; thence on there was steady improvement, 
with a good condition and a fair appetite. But still a frequent pulse was present; 
nothing abnormal could be noted in the heart. 

Suddenly upon February 19th, early in the morning, with a clear mind, clonic 
spasms occurred in the left half of the body, followed by slight left-sided hemiparesis 
and some mental confusion. Upon the afternoon the spasms recurred but were limited 
to the left extensor digitorum pedis. Upon April 6th, the child was brought to my 
office, spasms had not recurred, no paralysis, heart normal, but upon April 7th, again 
left-sided spasms occurred in the arm and leg, which increased from time to time in 
severity so that in the second half of May they occurred daily. From then until October 
the spasms did not cease, occurring almost daily, and only by an energetic bromid 
treatment were they somewhat suppressed. Other disturbances of the cranial function 
were absolutely absent. Intelligence was retained. Also the power of movement in the 
left half of the body was but very slightly influenced. Since that time I have not seen 
the child. 

It can scarcely be doubted that here a superficial meningo-encephalitic 
focus had developed over the right central convolution during the attack of 
scarlatina. The spasms had the entire character of those occurring in Jack- 
sonian cortical epilepsy. 

Combinations of scarlatina with other specific infectious diseases occur 
with great variations. 

Especially important is that occurring with baciUanj genuine diphtheria. 
Quite often not only in the same locality do scarlatina and diphtheria occur 
endemically — which has led to the erroneous assumption of a close relation- 
ship of both diseases and especially of scarlatinal diphtheroid with true 
diphtheria — but even in one and the same family scarlatina and true diph- 
theria may occur side by side. I have noted instances of this in which 
children suffered from unquestioned scarlatina without diphtheria, whereas 



714 SCARLET FEVER, SCARLATINA 

the father simultaneously suffered from baeillary diphtheria which was fol- 
lowed by severe, prolonged paralyses. 

If both affections combine in the same organism, it is much less serious 
if diphtheria is added to scarlatina than inversely. Each year, in the clinic, 
one or the other case is observed in which genuine Loffler bacilli can be detec- 
ted in the pharyngeal parts, these areas then for the most part being cov- 
ered by dense membranes. If the specific treatment is begun at once, the 
second infection does not materially add to the difficulties of the first, even 
if the scarlatina should be of a serious character. This I saw in a severe 
scarlatinal diphtheroid, in which later on, not only new deposits in the 
pharynx but also the walls of a deep and distributed ulcer cavity in some 
lymph glands in the neck covered with membranous deposits occurred. 
Everywhere the typical Loffier bacillus could be demonstrated. After spe- 
cific treatment, which was employed at once, the diphtheria rapidly disap- 
peared and finally the very ill child recovered completely. Naturally, when 
the true character of the pharyngeal affection is not recognized, that laryngeal 
stenosis, descending croup or true diphtheritic paralyses may follow a " scar- 
latinal diphtheria " is easy to understand, but does not alter the fact that 
the usual diphtheroid pharyngeal infection has nothing in common with true 
diphtheria. 

The condition is much more serious if a scarlatinal infection is second- 
arily added to diphtheria. Then it avails but little that the primary affec- 
tion has been successfully and specifically treated. In the winter of 1894-95, 
while the curative serum treatment was in full swing in the diphtheria 
division of my clinic, a scarlet fever epidemic of 12 cases occurred, almost 
all arising in November and December. The original diphtheria patients for 
the most part were medium severe cases and were at once treated with curative 
serum; in spite of this, 3 of the 12 cases died, therefore 25 per cent. The 
originally diseased diphtheritic parts, after the appearance of scarlet fever, 
were attacked by a hemorrhagic necrotic inflammation. The transition of 
the membranous diphtheria to a necrotic and ulcer-forming diphtheroid in- 
flammation could be well followed. The cause of death is always due to 
sepsis, in one case with the addition of jaundice, in another of the hemor- 
rhagic diathesis. 

The combination of varicella and scarlatina, especially if the former is 
added to the latter, runs its course without disturbance. Not rarely is scar- 
latina added to varicella in the manner that the erythema, as from a wound, 
takes its point of origin from a scratched varicella pustule. Then the scarla- 
tina does not always run a favorable course but develops a stubborn nephritis 
or other complications. 

Once, in a girl aged nine years, I saw scarlatina develop in connection with varicella. 
To the scarlatina there was added a severe erythema exsudativum multiforme, to this 
simultaneously there was also added hemorrhagic nephritis and a severe hemorrhagic 
diathesis resembling scurvy, with marked hemorrhages from the gums and, finally, 
measles appeared. But from all these diseases, after an illness of three months, the 
child finally recovered completely. 



DIAGNOSIS 715 

Occasionally in convalescence from scarlatina, the appearance of purpura 
is noted. Two cases which occurred a year or two ago in my clinic, afteT a 
few weeks, terminated in complete recovery. 

Regarding the complication of measles and scarlatina this has been de- 
scribed under measles (which see under Measles). 

Puerperal scarlatina, according to the investigations of Sorensen, as well 
as of other authors, is nothing else but the usual scarlatinal infection which 
finds entrance by way of the damaged parts. The previously mentioned 
author found the diphtheroid infection in the perineum and in other wounds 
of the genitalia instead of in the pharyngeal organs. 

In a pregnant woman aged thirty-five (toward the end of pregnancy), 
upon the third day of the disease, I saw the birth of a dead child; there 
were no signs of the eruption present. A woman aged thirty-four years who 
was nursing her child during a medium severe attack of scarlatina kept on 
nursing without the child being attacked. 

DIAGNOSIS 

In well developed cases the scarlatinal rash has a characteristic appear- 
ance. The fine, delicate, closely situated elevations seen at the onset of the 
disease, which, after the general cutaneous exanthem has appeared, remain 
during the entire course, are not met with in the same manner in other erup- 
tions of a similar nature. At most, the " triangular form " of the prodromal 
variolous eruption might be assumed which sometimes exactly resembles the 
scarlatinal exanthem, even including the deep fine elevations, but this is so 
limited to a triangular space upon the thigh or the shoulder that the differ- 
entiation may be very readily made. 

But there are acute diseases in the early period of which a scarlatinoid 
exanthem, an eruption, appears simulating a form which is not rare in scar- 
latina and which may then give rise to grave errors. This is noted in enteric 
fever and in acute lobar pneumonia in children as well as in adults. General 
cutaneous erythema even with succeeding mild desquamation particularly 
occurs in the first days before the previously mentioned characteristic symp- 
toms of the disease have developed. I know of a case in a lady whose severe 
enteric fever which terminated fatally was incorrectly looked upon as scarla- 
tina by a prominent diagnostician. In children I have much more frequently 
known the mistaken diagnosis of pneumonia to be made. It will always be 
well to remember the small prominent points in the exanthem before a diag- 
nosis of scarlatina is made. 

Besides there are also toxic exanthems which may give cause for confu- 
sion to less experienced physicians; thus, we occasionally see drug eruptions 
of a scarlet red color produced by quinin and antipyrin, but the injection of 
the deeper layers which is so characteristic of scarlatina (upon pressure with 
the finger), the rate blanche, and the unevenness of the skin are absent. For 



716 SCARLET FEVER, SCARLATINA 

a long time the similarity of the rash of atropin to that of scarlatina has 
been known, which even once led to regarding belladonna as a preventive 
against scarlatina. Further, the toxic products contained in the serum of 
animals often lead to a scarlatinoid eruption. These forms of serum exan- 
them, especially in the diphtheria departments of hospitals, often are the 
cause of great anxiety. They may appear with severe fever, with headache 
and vomiting, and not infrequently are the palatine parts inflamed, even new 
deposits occurring. Briefly, the entire picture of beginning scarlatina is 
present. There are cases in which the question whether we are dealing with 
scarlatina or not, must remain undecided — even the combined opinion of such 
experienced eyes as those of a Widerhofer and of a Kaposi have been impos- 
sible to decide this question at a first glance. 

In these cases another property of the scarlatinal rash which makes the 
diagnosis difficult must be considered: that it by no means always reaches 
the full development which was previously described as so characteristic. 
On the contrary, in unquestioned cases it quite frequently remains in a stage 
of pale, indistinct, rose-colored maculae, in which confluence does not occur, 
without attaining a scarlet color during its entire course. Sometimes even 
distinct spots do not appear but we only find a slightly developed erythema 
upon the trunk and upon individual parts of the extremities. Exanthems 
of this kind naturally occur in quite a number of other affections. Apart 
from the eruption due to serum, we find this in a well developed manner in 
the scarlatinal form of rotheln. But it will be opposed that this disease runs 
i*ts course without fever ! That would be a decided point of difference if 
there were not cases of scarlatina without fever, or at least with onl} r a slight 
initial rise, which may have disappeared at the time of observation. A short 
time ago, when in consultation with one of the first physicians of Berlin, I 
had to give an opinion in a case in which he was in favor of scarlatina, while 
I was in favor of rotheln, without either of us being able to give decisive 
proofs for his opinion. The further course of the disease favored my opinion 
in so far as no nephritis or other serious difficulty arose. In these difficulties 
it becomes quite clear how much the clinician owes to the bacteriologist, in 
all those cases in which an unquestioned etiological diagnosis is possible. 
At the bedside, in doubtful cases, it would be well to examine the entire 
surface of the body; frequently, at least here and there, an area is noted in 
which the fine papular character of the rash shows the nature of the disease. 
Also the conditions of the oral and pharyngeal cavities which will be described 
later may aid in this. 

An influenza, also with cutaneous erythema, occurs, which may resemble 
a feebly developed scarlatinal eruption. A few years ago, in the family of 
a colleague, I was required to give an opinion in which, simultaneously, 
fever, and an angina with a beginning exanthem were present; the rash hav- 
ing the character of a fleeting form of scarlatinal erythema. Only the cir- 
cumstance that almost within five days all the cases occurred suddenly, all 
the patients being ' adults, and in a short time recovered without compli- 



PROGNOSIS 717 

cations favored influenza against scarlatina. As no expectoration was present 
no decision could be given by a bacteriologic investigation. 

Finally, cases occur in which the exanthem of scarlatina does not present 
its usual appearance, especially upon some areas of the body, as, for example, 
the arms and legs — with the trunk remaining almost entirely free — where 
it shows a coarse macular and partly papular condition, which is common to 
measles. In these cases the correct course will be indicated by the character 
of the mucous membrane changes. 

The diagnosis may become very difficult if the exanthem shows itself in 
a rudimentary character or is absent altogether. In the former instance the 
correct trail can often still be found if it is only not forgotten that the entire 
surface of the body from head to foot must be minutely examined, especially 
also the posterior surface of the body, the elbow, the popliteal space, etc. 

Where no eruption is present at all, auxiliary circumstances must decide: 
The circumstances in the surrounding of the patient, the onset of the disease 
with vomiting, a disproportionately high pulse, etc., and often the later appear- 
ance of marked desquamation may show the true significance of the case. 

In such cases in which a suspicion is entertained, the condition of the 
oral and pharyngeal cavities must be observed. The strawberry tongue, the 
sharply defined, deep red appearance of the velum of the palate, of the uvula 
and of the palatine arches, the marked deposits on the tonsils, the flow from 
the nose, the intense swelling and painfulness of the lymphatic glands justify 
the assumption of a latent scarlatina. The deposits upon the tonsils and the 
other palatine parts in this form of scarlatina often show an exquisitely mem- 
branous character, especially in the first days, so that unless a bacteriological 
investigation is made, primary diphtheria is much sooner supposed to be pres- 
ent than a diphtheroid. The diphtheria divisions in hospitals are frequently 
endangered by such cases, namely, by the introduction of scarlatina. 

This shows the great practical importance of a correct diagnosis in all 
questionable cases that have been mentioned, in that the feebly developed, 
quite rudimentary eruptions, and even those of infections that run a course 
without rash, are capable of conveying the disease to predisposed organisms, 
which in the latter may show a severe course and give rise to a fatal issue, 
and this may occur quite as readily as by the fully developed cases of scar- 
latina. For this reason the greatest caution is necessary even in every sus- 
picious case. 1 

PROGNOSIS 

The general prognosis of scarlatina depends upon the character of the 
epidemic, which, as has been expressly mentioned, varies greatly in different 

i A generalized erythema may be caused by intestinal autoinfection. Improper food, 
fat feeding, the " top milk " prejudice, in some even unmixed milk feeding, will cause it. 
Then indican, skatol. indol are found in the urine, often with more or less symptoms of 
kidney irritation, microscopic blood, hyaline casts, also fine granular casts. Often in- 
crease of temperature. — Editor. 



718 SCARLET FEVER, SCARLATINA 

periods; also in different countries, and in different races, the prognosis is 
not the same. In my private practice in Leipzig, lasting for fifteen years, 
in which I had to do with the district poor, which, therefore, represents the 
least resistant part of the population, in 358 cases I had a mortality of 13.4 
per cent. We must, however, admit in the case of scarlatina that the influ- 
ence of better conditions of life plays a much less important part regarding 
the chances of recovery from the disease than, for example, in the case of 
measles. Jurgensen, in Tubingen, among 547 cases, had only a mortality 
of 8.23 per cent.; in Stockholm, according to this author, the mortality in 
different years varies between 2.8 per cent, and 28.8 per cent., upon the aver- 
age 10.3 per cent.; in England, the mortality varies from 13 per cent, to 
40 per cent. In Norway, in ten years, Johannessen found an average mor- 
tality of 16.6 per cent, (in children). From these figures so much can be 
concluded that an individual epidemic, especially in England, may become a 
calamity almost resembling the most terrible well-known pestilences. 

In the individual cases there are very few acute diseases in which it is 
impossible for so long a time to give a certain prognosis as in scarlatina. 
This is due to the fact that even in very mild cases the affection at the onset, 
even at the end of the third week or later, may show a change due to nephritis, 
which may threaten life or at least produce chronic invalidism. Nevertheless, 
a regular uniform course — oftener with a well developed exanthem than with 
a feeble or rudimentary one — during the first week of the disease may be 
looked upon as a favorable prognostic sign. 

Any deviation, no matter how mild, a slight rise in the fever, renewed 
swelling of the glands, etc., never remains isolated but opens the road to all 
possible serious consequences. Even in private practice rendering a prognosis 
is greatly facilitated by the keeping of a regular temperature chart : the fever 
in this instance is a very accurate prognostic indicator. Especial importance 
should be given to the second half of the first week, in which the first signs 
of diphtheroid or of otitis media become noticeable, and to the turning 
point between the second and third weeks, in which nephritis is most liable 
to occur. 

For the prognosis of a severe case with cranial manifestations, three symp- 
toms in particular appear to me to be especially unfavorable: jactitation, 
dyspnea, with loud respiration, and abnormal frequency and smallness of the 
pulse (as well as the other signs of cardiac asthenia). Severe stupor, or 
marked delirium are in themselves by far less dangerous phenomena. 

In diphtheroid, the unusually marked enlargement of the glands and the 
coarse periglandular infiltration which occurs early are very unfavorable prog- 
nostic symptoms, as are also a very markedly rising fever, or an otitis media ; 
the prognosis goes hand in hand with the severity of the fever in general. 

Finally, in nephritis — at least in most cases — the most certain indicator 
of immediately threatening danger is the decreased quantity of urine excreted. 
By the mere estimation of the albumin and also by microscopic investigation 
of the sediment by no means so accurate an opinion can be gained in regard 



PROPHYLAXIS AND TREATMENT 719 

to the condition as by measuring the daily quantity of the urine. For this 
reason, even in private practice, we should in no case of nephritis neglect to 
measure the quantity of urine for each twenty-four hours. 

Finally, the age of the patient is not without importance in the individual 
prognosis. In the interval from the first to the fifth, and especially from 
the second to the fourth year, life is mostly threatened by the manifold 
dangers of scarlatina. 

PROPHYLAXIS AND TREATMENT 

The prophylaxis of the disease consists chiefly in the prevention of con- 
tact between the sick and the well in so far as is possible, and only the dis- 
eased human being presents the danger of further distribution. The attain- 
ment of this end should be worked for, as the scarlatinal infection need not 
attack every person who is exposed to it, for the susceptibility to the poison 
decreases with advancing years and, on the other hand, every infection may 
lead to a malady dangerous to life. This course is more easily prescribed 
than carried out, as, especially in families with many children closely crowded 
together, the separation of the sick from the well is often quite illusory, but 
even among the better situated classes of the population there is great diffi- 
culty with this prophylaxis, as the disease, especially in adults, appears in a 
form which is not readily recognized, showing but the usual angina, but which 
fact does not materially interfere with the transmission of the disease. Just 
this circumstance, however, makes it our imperative duty to prevent contact of 
those around the scarlet fever patient with others free from the disease, thus, 
they should not be allowed to go to school, to infantile institutions, kinder- 
gartens, hospitals, etc. Difficult as it may be for the affected family, the 
brothers and sisters of the scarlet fever patient must remain isolated during 
the entire time of the disease. In many countries this is required by law. 

The question is often asked of the physician whether the healthy nurses 
or relatives of the child may visit other families, may receive company, travel, 
etc. Particularly in regard to the possibility of the transmission by the 
healthy, or at least apparently healthy, I would advise prohibiting this. 
Transmission by the physician from one sick-bed to another or to his own 
family is not likely as the visit of the physician to the bedside is usually a 
very brief one and a sufficient quantity of poison does not adhere to him. 
If only he does not have a latent, unsuspected scarlatina himself! Yet the 
greatest cleanliness and care is absolutely necessary even on the part of the 
physician. Wherever possible, his visits to patients of this kind should come 
at the end of his visiting list, and the custom which is coming into vogue 
of covering the clothes with a linen gown in visiting the sick should perhaps 
be generally introduced. 

Particularly difficult and important is the question of disinfection of the 
sick-room after termination of the disease. This involves great inconvenience 
and often enough decided injury to the infected individual, and also in not 



720 SCARLET FEVER, SCARLATINA 

a few cases its value lias been shown as illusionary, and we must actually 
admit that it has not been strictly proven that the poison of the disease may 
adhere to the sick-room in a condition capable of further dissemination. In 
most cases of this kind, when the disease has terminated (for example, by 
death) and the poison has still shown itself to be active, there remains the 
possibility that it has been present in the oral cavity of a person who has been 
active about the patient. Nevertheless, in view of our present knowledge of 
the nature of the scarlatinal poison, it is perhaps impossible to avoid unnec- 
essary measures. 

All these difficulties could to a great extent be avoided if in every case of 
scarlatina (as also in other infections), instead of sending away the well 
children as is usual, the entire population would agree to send away every 
sick child after the disease has been determined with certainty. In order 
to carry out this plan it would be necessary to have more well-equipped 
hospitals for treatment of contagious diseases than exist at present, as do 
some other countries (America, England, Denmark, Sweden). Where these 
opportunities exist they are at present largely shared by the rich and the poor, 
this being shown by the experiences in Stockholm, with the new infectious 
hospital erected there, and I have also observed this since the erection of the 
new Children's Hospital in Leipzig. With increasing frequency, the first 
families of the city come with their children sick of scarlet fever or diphtheria 
to the hospitals to have them treated there. Especially in regard to the 
better situated classes, it is necessary, in the erection of such hospitals, to make 
it possible that the mother may accompany her child. Yes, even more. The 
families should not be required in such cases to give up their physician who 
has perhaps been attending them for years for one- who is unknown to them, 
nor should the dignity and position of a thorough family physician be sacri- 
ficed by allowing his patients to pass into the hands of any other physician. I 
see the solution of the dilemma only in this, that, according to the example 
of the many sanatoria which exist in large cities, in which infectious patients 
are taken, every practising physician should be allowed to continue treating 
his patients with or without the cases being accompanied by relatives. Noth- 
ing is changed but the sick-room. Transportation among the first hours or 
the first few days of the disease is always possible. In the course of time a 
system of this sort is bound to develop. 1 

That, naturally, there should be a disinfection of all utensils and objects 
which have come into contact with the patient, bed, toys, etc., which may be 
contaminated with the poison, and are, therefore, dangerous, is clear. They 
should be disinfected and if possible destroyed. It is impossible to enter 
here more minutely into these hygienic questions. 

Simple scarlatina has a typical course which, so long as we are not in 
possession of a specific remedy, had better not be disturbed by interfering 

i Without any criticism of our defective American conditions, I merely wish to 
direct the attention of the reader to these lines. — Editor. 



PROPHYLAXIS AND TREATMENT 721 

measures. The object of the physician consists in the widest sense in order- 
ing the diet and in superintending the nursing. The patient in most cases 
goes to bed of his own accord and even in the milder cases should be kept 
there for at least three weeks and not allowed to get up, until by a careful 
examination of the urine which has been saved for twenty-four hours it has 
been shown that the kidneys have been spared. This indication should be 
carried out under all circumstances. 

Wherever possible — even in small dwellings — the patient and the nurse 
should each have a room. The rest of the family during such an unfortunate 
time must make up their minds to suffer some inconvenience. In better 
situated circles wherever possible two neighboring rooms should be used. As 
soon as the disease has been recognized the physician must prevent the other 
children from going to school. What a calamity this is, in the narrow rooms 
which often represent living room and kitchen in workmen's dwellings, may 
be imagined. I have had some experiences which would scarcely be believed. 
Therefore, in such instances it is our duty to use all our influence toward 
sending the sick child to a hospital. Naturally, often enough the money 
question is in the way, provided the case occurs in a family that has recently 
come to the city (in Germany). The patient must not be allowed to have 
company. 

The sick-room is to be kept rather cool than warm, from 64° F. to 68° F. 
is sufficient. The covering for the fever patient is to be light. The child is 
to be supplied with fresh body linen and bedclothes, which during the disease 
must be carefully (previously warmed) renewed. The nutrition in the first 
three weeks should consist of a pure milk diet which may be varied in many 
ways (adding some coffee, bonny clabber, buttermilk, rice and milk, milk and 
grits). The assumption that by these means the development of nephritis 
may be prevented is erroneous, but it is possible that by a too early adminis- 
tration of food containing extra amounts of albumin the kidneys may be 
irritated and nephritis caused in this manner. 

The skin as well as the mucous membranes must be kept scrupulously 
clean; wherever possible, and especially if the children are accustomed to it, 
the patients are to have a quick luke-warm bath daily. In other cases the 
face, hands and feet, and any soiled parts of the body are to be washed with 
luke-warm water and soap. Especial attention is to be given to the daily 
cleansing of the nose, by cotton tampons which have been moistened, and 
the careful washing of the mouth and pharyngeal cavity, and by frequent 
active or passive cleansing, such as gargling with a luke-warm, dilute salt 
solution. This is to be repeated five to six times daily. It is advisable to 
use cheap substances such as cotton or the like, which immediately after use 
may be collected and burned. 

For the thirst, dilute acid drinks, lemonade or the like or boiled water 

with a little citric acid and sugar, are given. Internal medication is quite 

unnecessary. I am decidedly opposed to the early use of antipyretics, those 

from the group of benzol derivatives. Only apparent success is attained and 

47 



722 SCARLET FEVER, SCARLATINA 

the regular course of the disease is disturbed. Where there is a necessity for 
influencing the fever, a plentiful amount of cool drink (but without the addi- 
tion of alcohol) should be administered, and there may be cool applications 
of towels doubly folded and moistened and applied upon the chest, abdomen, 
and thighs, these being covered by woolen cloths. These applications may be 
readily fastened around the abdomen by means of bandages. In marked coma 
and severe delirium one or two, perhaps more, hike-warm baths are given at 
a temperature of 91.5° F., with cold affusions. The technique has been 
described in the treatment of measles. During the period of desquamation, 
this is favored by luke-warm cleansing baths. In cases in which there is 
marked itching or burning, inunctions with washed lard which were for- 
merly so much used may be employed or a 1 per cent, thymol-lanolin salve 
may be of value. 

Thus, convalescence is awaited and only the course of the temperature is 
carefully observed so as to be prepared for threatening danger. 

If such dangers develop, prompt interference is necessary even in des- 
perate cases, if only to give the parents the satisfaction of feeling that no 
measure that is known to professional skill has been neglected in the attempt 
to save life. 

Before entering upon the discussion of the treatment of the individual 
varieties of anomalous scarlatina, a few remarks regarding general treatment 
which influences the scarlatinal process may be in place. 

The most important is the attempt to introduce a serum therapy. This 
depends upon investigation showing that the recovery from scarlatina confers 
immunity toward the infection for the one that has recovered; this immunity 
is referred to the presence of antitoxins in the blood of the convalescent. As 
well as in the case of the animal that has been inoculated with diphtheria, in 
which the antitoxin-containing blood serum shows a curative action, so also 
the serum of a scarlatina convalescent is said to remove the dangers of blood 
intoxication clue to the scarlet fever attack. It is clear that this serum 
therapy is erected by hypotheses and should not be mentioned in the same 
breath with the accurately determined diphtheria serum therapy which has 
been proven by experiment. We are not familiar with the scarlatinal poison, 
we do not know whether it forms toxins, nor whether the scarlet fever immu- 
nity is due to the permanent presence of antitoxins in the blood. And even 
if this were the case it would be very questionable whether small amounts of 
the blood of convalescents which contain so much antitoxin would combine the 
hypothetical poison in a second organism. It must be remembered that in the 
case of diphtheria, the animals which furnish the antitoxin have been exposed 
to an enormously increased severe infection before their blood shows curative 
properties. Thus, theoretically, the thought of serum in the therapy of scar- 
let fever in its present condition does not promise very much. I should 
believe that trials would only be justifiable in those desperate cases in which 
all other previous measures have proven ineffective. In these cases every 
rational attempt is permissible. 



PROPHYLAXIS AND TREATMENT 723 

Another general treatment has recently been advised by Seibert x in New 
York : Repeated inunctions of the entire body several times daily with a 5 
per cent, to 10 per. cent, ichthyol-lanolin salve. Every six hours the entire 
surface of the trunk and the extremities is, with slight pressure, to be 
anointed ; in each inunction, according to the size of the patient, 30 to 90 
grams are to be used. I have employed this method quite frequently, most 
children bear the inunctions very well and sometimes it appears to influence 
the temperature and general condition of the patient. The method is quite 
difficult, requires much body linen and is very expensive. Of actually severe 
cases, none have been saved by it, for this reason I have abandoned the treat- 
ment. Kraus reports from Ganghofner's clinic, rather an exacerbation of the 
cutaneous affection by the ichthyol inunction. I have not observed this. 

Nor have I seen success from inunctions with Crede's argent, colloidale nor 
from the subcutaneous use of Marmorek's streptococcus serum. Wherever 
the treatment has been carried out, it was unsuccessful in a number of cases 
before being abandoned. 2 

Thus, until now the hope of a successful treatment of the indicatio morbi 
has not been attained. 

We shall now turn to those measures which have shown themselves useful 
in the individual cases in which complications have arisen. 

The treatment of scarlatina gravissima, according to my experience, is 
entirely hopeless. I have never seen a case recover in which the diagnosis 
was at all certain; the strongest analeptica (up to 1.5 grams camphor subcu- 
taneously in twenty-four hours), antipyretics, hydrotherapeutic measures, are 
of no avail here; nevertheless, in every instance the attempt must be made 
to combat the disease with all the energy at our command, and, besides, some 
cases which are characterized b} r especially intense fever and severe nervous 
symptoms resemble the severest form, although they are favorably influenced 
by the remedial measures now to be named. 

Above all, the cooling and stimulating effect of the water treatment 
must be considered. The very rapid rise of the body temperature to a great 
height, which in itself is dangerous, requires a purely s} 7 mptomatic with- 
drawal of heat. I cannot advise the employment of cold baths for this pur- 
pose. I used them formerly but I find that the infantile organism upon the 
whole does not bear them well, and that in the case in question, in which 
there is almost constantly a cardiac weakness present this is a contra-indica- 
tion. I prefer for this purpose repeated packs, the influence of which may be 
extended to an hour, without causing a decided internal congestion of blood 
as is the case with a cold bath. For this purpose two beds, each supplied with 
a sheet and woolen blanket, are necessary. The cover and the sheet, which 
have been wrung out in cold water (at 59° to 60° F.), are spread out, the 

iJahrbuch filr Kinderheilkunde, Bd. li,.p. 308, 1900. 

2 I have a strong impression that a few of my very bad septic cases recovered under 
the use of the serum, " Remedium anceps melius nullo." A doubtful remedy is better 
than none at all. — Editor. 



724 SCARLET FEVER, SCARLATINA 

naked child is enveloped up to the neck, first in the sheet then in the woolen 
blanket, and allowed to remain so for ten minutes (or if the hyperpyrexia is 
not so marked, for fifteen minutes). In the meantime the second bed has 
been prepared in a similar manner and the child after it has been taken from 
the first pack is immediately enveloped in the second for ten (up to fifteen) 
minutes, and so forth for an hour, so that the decided cooling is repeated from 
four to six times. The difference between this method of cooling and a cool 
bath are obvious enough ; between the renewed coolings the sheet warms itself 
inside of the woolen covering and the blood remains upon the surface of the 
skin. The result of the cooling is very energetic. This procedure must not be 
employed more frequently than two, or at most three times a day. In the 
intervening periods the child is to be allowed to rest. 

Secondl}', in those cases in which there is marked nervous implication, 
cold affusions in a warm oath are of use. The duration of this (temperature 
90° to 95° F., according to the condition of the pulse) may be five, ten, or 
even fifteen minutes (in older children), but may also be very much short- 
ened. The principal indication here is the cold affusion. The children are 
comfortable in the warm fluid, which, compared with the temperature of the 
body, is always 12 to 15 degrees lower, and now the beneficial contrast for the 
nervous system, the cold, " the cold shock " occurs. From a slight height 
water cooled by ice is poured over the head, neck, back, and chest, in short 
intervals according to the length of the bath; at least 5 to 6 litres are to be 
used. The external auditory meatus is to be closed by plugs of cotton. The 
parts of the skin upon which the cold water is poured are to be gently rubbed 
during this procedure as well as the trunk and extremities which remain in 
the bath. Each affusion causes deep respiration that cannot be attained by 
any other method, therefore, a very decided area of the lungs is influenced. 
Quite a number of other reflexes also occur. The effect upon the centres in 
the medulla cannot be mistaken. The baths are repeated four, even six times 
daily. Usually after this procedure children will take a larger quantity of 
nourishment, which is followed by quiet sleep. 

A third process has for its object combating the cardiac weakness. There, 
in my opinion, alcohol is absolutely necessary. Strong, old red wine, and 
especially champagne, stimulate the cardiac and vasomotor activity so long as 
the greatest danger appears to be present. After this has passed the alcohol 
may be discontinued. 1 But during the storm of the life-threatening symp- 
toms, it is well not to be too sparing with it. Other analeptica are to be 
utilized at the same time, especially camphor, which in an oily solution may 
be given hypodermically every two hours or even oftener. Of a 20 per cent. 

i It should not be discontinued too early. It is the best remedy in sepsis. While this 
lasts no dose is too large. No intoxication by alcohol takes place during bad sepsis. 
The best oil to dissolve camphor in is that of sweet almonds. The useful, very useful, 
preparations of caffein are the double salts: Sodio-caffein salicylate or benzoate. They 
are easily dissolved in 2 parts of distilled water. Fifteen minims contain 8 grains 
of the salt, equal to about 4 grains of caffein.— Editor. 



PROPHYLAXIS AND TREATMENT 725 

solution, according to the age, I give from one-half to an entire Pravaz syringe- 
ful per dose. 

By French authors (Moizard) the subcutaneous injection of caffein (10 
per cent, solution of sodium salicylate of caffein, one-third to a syringeful to 
a dose) and where the nervous symptoms, besides asthenia, are especially devel- 
oped, sulphate of spartein (-1 per cent, solution, one-third to one-half syringe- 
ful to a dose) is advised. I have had no personal experience regarding these 
procedures. 

The treatment of diphtheroid, above all things, requires a frequently re- 
peated cleansing of the oral, nasal and pharyngeal cavities. Even the simple, 
frequently repeated drinking of pure water, or water containing some acid 
fruit syrup, is of value; but drug treatment must be added. There are a 
large number of disinfectants which may be used in solution, as a gargle or 
mouth wash, or may be insufflated into the mouth and nose. Boric acid (5 
per cent.) is a favorite, but is not especially active, also salicylic acid (1 to 
100), or hydrogen peroxide (3 per cent.) may be employed. In the last few 
years ichthyol has appeared to me to be of especial value. I use it almost 
exclusively in the form of a 5 per cent, solution of ammonium or sodium 
sulphoichthvolicum. I have used it much in private practice and have heard 
many physicians praise it. The disagreeable taste of the solution is unpleas- 
ant, so that some very sensitive children object to it; usually, however, this 
repugnance can easily be overcome upon the second daj-. The application 
occurs in older children in the manner that after washing or gargling with 
pure luke-warm water (to remove the mucus masses or remains of food) 
the same process is repeated with the ichthyol solution. In younger children 
the same object is accomplished by means of a tube, syringe or irrigator. This 
process has the advantage that under all circumstances the disinfecting fluid 
also reaches the posterior and lateral pharyngeal wall, which is not the case 
with simple gargling. 

The syringe must not be used through the nose, but a small quantity of 
the disinfecting solution may be poured into each nasal opening by means of 
a spoon or the like, it is then allowed to flow out by the mouth ; small quanti- 
ties are naturally swallowed. Or a tampon of cotton, having been dipped in 
the fluid, is pressed out in a similar manner as was described in the chapter on 
the treatment of measles. Previous to this, each half of the nose is to be 
cleansed, as carefully as possible, by means of small pellets of cotton. For 
nasal disinfection, insufflations are also valuable, for example, of the sodium 
sozojodol powder mentioned under measles. By these remedies the surface of 
the diseased mucous membrane may always be denuded and thus prevent the 
increase of the dangerous streptococci. 

If, however, necrosis of the mucous membrane has occurred in extended 
areas in the naso-pharyngeal space, these septic microbes are no longer in 
reach of superficial washings for they are already proliferating in the deeper 
tissues. 

We even now possess a method of reaching them or at least of causing 



726 SCARLET FEVER, SCARLATINA 

some attenuation, even if not destroying them, in the subcutaneous injection 
of antiseptic remedies into the palatine areas, a 3 j)er cent, carbolic acid solu- 
tion being best for this purpose. The object of this treatment is not to influ- 
ence the diphtheroid locally but to introduce these solutions into the roots of 
the lymph vessels which lead to the lymphatics of the lower jaw. The anti- 
septic is to take the same road which the mass of septic streptococci takes as 
well from the nasal as from the oral cavities, and to meet them in the lymph 
vessels and lymph glands and render them harmless. The proposal for this 
method of treatment, which I mentioned in 1886, has been accepted by a num- 
ber of pediatrists, who like myself were satisfied by the results attained. Its 
general introduction into the treatment of scarlet fever has not yet taken 
place, but I have used this method for over twenty years and have not 
given it up, for it appears to me that it is more valuable than anything else 
that has been tried. For the injection, a Taube cannula is employed ; this is 
attached to a Pravaz syringe, injections being made twice daily into each half 
of the palate (tonsil and anterior velum of the palate, arch of the palate), 
half a syringeful being employed, therefore, in all 0.6 phenol daily. The 
manipulation in this process is easier and simpler than the previously used 
method of making applications to these parts. If a brown color of the urine 
occurs this treatment is stopped. The method is begun as soon as the rise 
in the temperature, which was mentioned in the clinical description, takes 
place, upon the fourth or fifth day, or an increase in lymphatic enlargement, 
etc., announces the danger of diphtheroid ; under some circumstances, in severe 
cases this treatment may be begun upon the first or second day. It is con- 
tinued until the glands become smaller, the fever declines or the condition of 
the oral and nasal cavities shows a tendency to limitation of the inflamma- 
tory necrosis. Not rarely more or less extensive necroses are found in the sur- 
roundings of the openings made by the needle. These are not caused by the 
carbolic acid itself, but are due to the severity of the local affection and may 
appear in the same intensity in areas in which no injection has been made. 
If necroses occur in wide distribution around the point of insertion I stop the 
injection in the infected half of the palate. In themselves these losses of 
substance, as has already been explained, are rarely of danger. 1 

The inflammation of the lymph glands, which very often takes a sub- 
stantive character, may be controlled at the onset by the application of ice. If, 
however, marked enlargement, hardness, or periglandular infiltration have 
taken place, then a warm poultice is more valuable to produce suppuration as 
early as possible so that an incision may be made. The incision of non-sup- 
purating necrotic glands as well as the excision of numbers of such infectious 

1 1 strongly emphasize the warning against the use of syringes. Irrigations of the 
nose from a cup which reach the fauces, of saline solution, of boric acid solutions, 
of corrosive sublimate (1 in 5,000 or 10,000, mainly the first) are curative and pre- 
ventive. They may be made often, every one to three hours. No use in destroying 
the child's muscular and cardiac powers by the struggles caused by forcing the mouth 
open. The mouth is accessible by the nose. — Editor. 



PROPHYLAXIS AND TREATMENT 727 

glands has as yet not been followed by favorable results. Regarding inunctions 
of mercury salve, of argent, colloidale, I have seen no other results than that 
they make the skin dirty and not infrequently produce excoriation. I leave the 
cutaneous coverings of these septically affected parts alone. Analogous to this 
a purulent parotitis should be treated. I have never seen this complication in 
scarlatina. 

Of greatest importance, besides the local treatment of the scarlatinal diph- 
theroid in the mouth and nose, is the attention which must be paid to the 
condition of the middle ear. The same is true here as was mentioned in the 
discussion of measles, which was accurately described and for this reason need 
not be repeated. 

Scarlatinal rheumatism is treated with the same symptomatic results as is 
polyarthritis, by antirheumatic remedies. I have not seen a justification of 
the fear that by their internal use the kidneys would be injured. Among 29 
cases of scarlatinal rheumatism in my practice, 3 later suffered from nephri- 
tis. This is exactly the same percentage which was observed in the total num- 
ber of cases. At that time the rheumatism was almost exclusively treated 
by salicylic acid. Now it is better to use the milder and more pleasant aspirin, 
but not in too small doses (afternoons at two, four and six o'clock doses each 
of 0.5 [7J grains]). As a rule two days of treatment is sufficient. The less 
severe cases may be treated by keeping the affected joints warm, the symptoms 
disappearing from them in from four to six days. 

In postscarlatinal fever, the ear and the posterior pharyngeal wall are to 
be carefully examined, regarding a possibility of absorption of septic material, 
the treatment being accordingly. Ichthyol washings of the posterior pharyn- 
geal wall from the mouth render good service. 

Scarlatinal typhoid is to be treated in the same manner as a mild attack of 
infantile enteric fever. There should be employed cool packs to the chest and 
abdomen, cool drinks, under some circumstances baths and drug antipyretics, 
but here, above all, quinin may be utilized. 

Scarlatinal nephritis in a great number of cases may take the simple 
course described and in the main requires but simple dietetic treatment. It 
is good practice so long as the amount of urine does not fall below 500 to 
600 c.c. to desist from active treatment. Milk diet is continued; and by all 
possible auxiliary measures (addition of some coffee or tea, with variation in 
the form of buttermilk, etc.) an attempt must be made to give as much of 
this food as possible (2 to 3 litres), so that the requirements of the body are 
completely covered. Besides milk, luke-warm drinks may be given (lemonade, 
tea) or some alkaline mineral water, but if at all possible there should be 
no other food substance so long as a sufficient quantity of milk can be taken. 
In those cases in which milk cannot be administered, which are not frequent, 
the food should consist particularly of vegetables; wheat bread with butter, 
dried or fresh vegetables, fruit soups, cereals, fruits. Many of these sub- 
stances may be prepared with milk and will be taken by those that reject pure 
milk. But the action of a mild diuretic, which milk if it be taken alone shows, 



728 SCARLET FEVER, SCARLATINA 

cannot be attained in this manner. Occasionally small quantities of milk will 
be taken frequently instead of large quantities at one time. 

The fever which occasionally accompanies nephritis need not be especially 
considered in the treatment, particularly as it is of brief duration. 

As soon as the urine secretion falls below -±00 c.c, showing a more decided 
injury to the kidney, active measures are necessary. With regard to the 
marked implication of the vascular system in the damage to the scarlatinal 
kidney, 1 hold that every measure which may produce an irritation is a two- 
edged sword, and prefer for this reason to spare the kidney in the acute 
stage. Even mild drug diuretics, as for instance potassium acetate, I do not 
employ, for I allow this function to be carried out by food and by drink. I 
prefer to make the skin active and to withdraw water by means of sweating. 
The best method consists in placing the patient in a warm to a hot bath 
(95° F. gradually rising to 100.5° F.), this lasting from ten to fifteen min- 
utes, and being followed by dry or moist packs. In cases in which fever is 
present the sheets may be dipped in cool water so that the heat may be with- 
drawn at the same time and even the bath may be cooler. The patient is 
allowed to remain one-half hour in the pack after profuse perspiration has 
appeared in the face. Then the covers are gradually removed, the skin is 
dried with warm cloths, and the patient is placed in the bed which has been 
previously warmed. This process is only to be carried out once daily. There 
are, however, children who in this manner at least cannot be caused to sweat, 
especially in the beginning, then warm tea may be taken during the pack; 
and in cases in which this does not act I have very often with advantage given 
a little pilocarpin. The subcutaneous injections of this remedy have been 
quite properly abandoned, but small doses internally appear to me to be but 
slightly if at all dangerous. At the onset of the pack the child is given 10 
grams of a solution of 5 centigrams of pilocarpin to 100 grams of water. 
Almost always, shortly afterward, slight vomiting and salivation occur and 
the enveloping material should be protected by a cloth which is placed before 
the mouth; soon afterward, however, sweating takes place. Frequently this 
method need be used but once, sweat following later without the use of the 
drug. 

In a favorable action 300 grams of fluid may be withdrawn from children, 
frequently, however, not more than 60 to 100 grams. As, however, according 
to Strauss, 1 the molecular concentration of sweat is decidedly under that of 
blood serum it is always a question whether by this procedure an absolute 
substitute of the renal function in regard to the removal of urinary substances 
is attained. On the contrary, it might be questioned whether the mere with- 
drawal of water would not rather tend to increase the concentration of the 
blood serum, producing an unfavorable action, in that uremic symptoms 
would be more rapidly produced. In fact, every experienced physician has 
seen one or the other example of the appearance of uremic phenomena soon 

i Fortschritte der Medicin, Bd. xix, Nr. 21. 



PROPHYLAXIS AND TREATMENT 729 

after a hot bath or a hot pack. But these are for the most part rare excep- 
tions, whereas usually a subjective and objective amelioration follows the 
procedure. However, the experience just described makes it necessary to watch 
the patient after this sweating process has been attempted, in order to note the 
momentary success. Perhaps the undoubted frequent use of this measure does 
not consist in the withdrawal of water but in the regularly marked flow of 
blood to the skin, in which way the main object is attained. 

The value of depriving the renal circulation of blood by direct withdrawal, 
with an increased experience, has become more and more unquestionable to me, 
so that I should like to advise this method of treatment rather than that in 
which sweating is produced. As soon as, with a decline in the excretion of the 
urine (immaterial whether this contains much or little blood), the first symp- 
toms of intoxication occur, i. e., headache, vomiting, I lose no time but apply 
to each renal region, according to the age of the child, one or two leeches. 
The succeeding bleeding is to be kept up for a little time afterward. Some- 
times I have seen that it has been rather severe and continuous so that com- 
pression or other measures were necessary to stop the hemorrhage. However, 
it is better when a little too much than too little blood flows. The leech 
itself withdraws about 10 grams of blood and if (with 2 leeches), therefore, a 
similar quantity, 15 to 20 grams, flows from each wound, this is of advan- 
tage. Soon afterward, in favorable cases, the secretion of urine rises again, 
and headache and nausea disappear. In the severer cases, however, the im- 
provement is not sufficient, it is transitory, and headache returns. Cloudiness 
of the sensorium and a convulsive attack are added. Then without more ado 
there should be a general blood-letting by means of venesection, by which 100, 
150, or even 200 grams of blood in older children, may be withdrawn. I have 
gathered quite a number of observations in my clinic as well as in my con- 
sultation practice in the last two years, in which venesection has been followed 
by life-saving success. This may be followed by a subcutaneous injection of 
a normal salt solution of 100 to 150 grams directly. The secretion of urine 
is permanently increased ; it is still bloody for some days, but is copious ; the 
convulsions do not return and the beginning amaurosis gradually disappears. 

If in a severe scarlatinal nephritis the kidney is examined then, with the 
extended stasis of the blood in the glomeruli, in the cortical capillaries, in the 
vasa recta, the connection is not very difficult to understand. Without increase 
of blood pressure, by means of the general diminution of the amount of blood, 
the renal blood channels can be more readily traversed. Besides, perhaps the 
removal of a part of the retained substances of the blood serves a further pur- 
pose. It may therefore be a condition which allows the organism to return to 
a normal state. A certain advantage is attained by the use of warm poultices 
in the renal region. 

After the danger of uremia is over, or at the same time with it, it is neces- 
sary to combat the cardiac asthenia in severe cases. Even the subcutaneous 
salt infusion is of value here. But the question arises, whether drugs should 
be used. Here, with rapidly approaching danger, camphor, even in repeated 



730 SCARLET FEVER, SCARLATINA 

large doses, is valuable, but more frequently instead of combating a rapid 
collapse we must treat a permanent and slowly advancing asthenia. Regard- 
ing the favorite method of treatment by digitalis, at least so long as the 
case is in the acute stage, I have an aversion, which is perhaps not justifiable, 
but which is based upon a momentary increase in injury and a fatal ending in 
a previous severe case of nephritis. Care in the employment of this potent 
remedy is necessary under all circumstances. 

Steffen advised in these cases of cardiac asthenia to administer ergot in 
fair-sized doses, three to four times daily. I followed his advice and employed 
the fluid extract. In fact it appeared to me to be occasionally useful in com- 
bating the dilatation which gave rise to cardiac weakness. 

Occasionally the subcutaneous injection of strychnia nitrate once daily has 
a beneficial influence upon the cardiac activity. 

Caffein should also be considered, as it shows a simultaneous action, as a 
stimulant for the weakened heart muscle and as a vasomotor remedy. Xat- 
urally, also on account of the simultaneous influence on the kidney, the remedy 
must be given guardedly. 

Then by plentiful nourishment the action of the heart may also be re- 
stored. According to the investigations of v. Xoorden, no great fear need 
be attached to the administration of other albumins than of the casein of 
milk, as was thought to be the case formerly. It is best in nephritic cardiac 
weakness to arrange the diet so that, with moderate quantities of albumin, 
carbohydrates are also mingled with the food. The treatment of these con- 
ditions requires the greatest care as well in the choice of a drug as in a 
nutriment. 

[As the result of a long and various experience I join in the author's warn- 
ing against the use of digitalis, mainly in acute cases of nephritis. Besides, on 
account of the frequency of vomiting, the drug should not be given because it 
causes vomiting. Its taste is bad, besides. Strychnin nitras or sulphas may be 
injected in gr. -fo to gr. 3V several times a day. The best salt of caffein 
is the salicylate or benzoate of sodio-caffein. As this double salt is soluble in 
two parts of water it is conveniently given Irypodermically. Internally 1 grain 
which contains \ gr. of caffein, may be given every hour or two hours ; more in 
older children. A small radial pulse indicates the use of nitrites. The sodium 
nitrite may be given internally in doses — daily — of 3 to 5 grains, the trinitrin 
(nitroglycerin) y^j- gr. — more or less — daily, in many broken doses. — Ed- 
itor.] 



DIPHTHERIA AND DIPHTHERITIC CROUP 

By A. Baginsky, Berlin 

Diphtheria is a contagious disease, directly transmissible from child to 
child, also indirectly from a third person and infected fomites. It is one of 
the most terrible scourges, and has appeared in decimating epidemics which 
are scarcely equalled by any other affection in the history of medicine. It is 
not our purpose at this point to report them, and we must refer to special 
publications regarding this point. From these it can be seen that the first 
epidemics go far back into ancient times, that the disease bore the name 
" Morbus aegyptiacus," and " syriacus," that on account of its terrible char- 
acter Spanish authors gave it the name " Garotillo " (so-called after the 
cudgel of the executioner) — and, on the other hand, by Swedish physicians 
it was given the name " Strypsjuka " (strangling disease). From these desig- 
nations, which were popular with the people, it may be seen that the danger 
of suffocation was the most prominent symptom of those affected, and that 
death by suffocation was the most feared result. And yet so many other 
characteristics were found in the ancient descriptions of the disease: The 
rapid prostration, the decline in the cardiac power, the condition of delirium, 
etc., jactitations, effusions of blood, etc., which all point to the fact that 
still another element other than the purely mechanical hindrance in respira- 
tion was included in the disease, and showed itself prominently by causing 
death. And this was perhaps the reason that, according to the mode of 
its appearance in one or the other form, two different diseases were distin- 
guished, and the actual suffocating disease which was later designated as 
" croup " by the Scotch, was differentiated on the other hand from that form 
which apparently caused death by poisoning. The clinical picture of the 
disease varied in spite of the plentiful opportunity for its observation, up to 
that time in which the great French physician, Pierre Bretonneau, combined 
the whole, and from a number of classical observations that could not be 
surpassed, called attention to the unity of the various forms, in that he showed 
the combination of the appearance of thick leather-like membranes in the 
mouth, pharynx and naso-phanngeal space, and with the changes in these 
structures, malignant and deleterious symptoms at the same time were present. 
Bretonneau had attached the greatest importance to these membrane-like path- 
ological formations, and also originated the name diphtheria (from fofy&epa, 
the skin), which the disease has retained. 

731 



732 DIPHTHERIA AND DIPHTHERITIC CROUP 

After these brief remarks regarding the name of the disease, we shall at 
once consider the clinical course and observe the manifold pathologic pictures 
which are combined in this conception of a substantive disease which shows 
so many anomalies. Unfortunately, the number of cases in every large hospital 
that treats this disease is so great and varying that it is possible to demonstrate 
almost everything which is designated as belonging to the diphtheritic process, 
even all the sequels and complications of the disease. 

Case History. — Boy aged three years, showing some pallor, apparently well nour- 
ished, with a moderately high temperature (101.3° F. to 102.6° F.), admitted to the 
hospital yesterday. The history did not show accurately the time at which the boy 
was taken sick, but the onset of the disease could not have been long ago as the little 
patient appeared to be well for a few days previous, ate and played. It can be heard 
from his crying that he has a clear voice, nevertheless, the tone is somewhat changed, 
it may be expressed as pharyngeal. Upon observing the throat externally, it appears 
to be somewhat thickened; upon palpation two glands at the angle of the jaw are 
enlarged almost to the size of walnuts; apparently they are painful. The skin of the 
patient shows a normal color, is not especially hot nor dry, nor is there marked 
perspiration. The physical examination of the thorax and abdomen shows nothing 
abnormal. The pulse is soft, but little tenseness in the radial artery. The pulse rate, 
upon which little importance must be placed in children, as it varies greatly under 
slight emotional conditions, is somewhat over 100 per minute. 

Upon examination of the mouth and pharynx it will be noted that the lips are 
dry, slightly covered with sordes; the tongue is red at the margins, white upon its 
upper surface. Upon opening the mouth wider, there are noted upon both tonsils and 
posteriorly on the wall of the pharynx a thick, grayish-white coating, arising from the 
surrounding tissues, apparently tightly adhering to the surface. The mucous mem- 
brane which has remained free is of a pale red color, not too darkly tinged, therefore, 
not specially inflamed, still it is swollen, perhaps slightly transparent as if moistened 
through and through. 

This corresponds with the classical description given by Bretonneau — " Diphtheria, 
a membranous coating which covers the pharynx." — The child has diphtheria. 

Before answering the question, " How has this disease originated, and to 
what symptoms does diphtheria give rise ? " let us attempt to form a picture 
of the course of this, apparently, by no means terrible affection. 

This can be seen from a second case history. Child about three years old, has been 
under treatment for a few days; it showed the same symptoms as the former case when 
admitted, but at a glance it can be seen that it is of an entirely different, much less 
severe type. Yet, if we did not know that a few days ago it was seriously ill, we 
should scarcely take it for a sick child on account of its joyful, happy disposition. 
The temperature curve of the child shows that the temperature, which was originally 
somewhat over 102.2° F., has gradually fallen to between 98.2° F. and 99.5° F. The 
pulse is soft, still over 100 per minute. There is no impediment to the respiration; 
the voice, as may be noted when the child speaks, is pure and the physical examination 
of the respiratory organs shows nothing abnormal. The two submaxillary lymph 
glands at the angle of the jaw, that can scarcely now be felt, are but slightly con- 
spicuous. The lips are smooth, of a pale red color. The tongue is still slightly coated. 
The pharyngeal mucous membrane appears upon the whole to be of a somewhat deeper 
red than normal. The tonsils are larger than normal and appear dark red, and upon 
close examination we still note here and there individual grayish-white streaks lying 
upon them, whereas the rest of the pharyngeal membrane appears red. Upon the 
posterior wall of the pharynx a broad thread of mucus of a yellowish-gray consistence 



ETIOLOGY OF DIPHTHERIA 733 

is noted. This is all that remains of the original grayish-white, thick membrane. 
The examination of the urine shows that there is nothing abnormal, especially no 
albumin is present. This has all occurred under the influence of an effective therapy, 
the diseased process having given way to an almost normal condition, and we are 
entitled to hope that nothing will occur which will prevent the speedy return of the 
entire process to complete health. 

Upon the basis of these two clinical histories, we shall enter upon a general 
discussion of the affection. 

Diphtheria is a disease that is communicable; it usually begins with fever 
and commonly arises from the pharyngeal organs or often from the nasal 
mucous membrane. It is characterized by pseudo-membranous yellowish-gray 
or dirty gray deposits which are adherent and invade the mucous membranes, 
showing a tendency to distribute themselves. The disease may appear in the 
mildest form, although with some little fever, with but relatively slight impli- 
cations of the general organism, and so appear and run its course as a local 
disease of the pharyngeal structures. 

The disease is not limited to climatic or geographical locations, it has 
appeared in the coldest as well as in tropical and subtropical regions, and 
everywhere has shown an epidemic distribution. Nevertheless, we cannot sup- 
press the impression that the affection shows a preference for the temperate 
and northerly zones; at least it shows itself there more frequently than in 
others, and its epidemics are of longer duration and perhaps also more severe. 
The highly situated portions of the different localities show no exemption from 
the appearance and distribution of the disease, neither does the constitution of 
the ground have an influence; the inhabitants of swampy areas are affected 
to the same extent as those of the mountain regions, the inhabitants of sandy 
and gravel districts as well as those dwelling upon more compact earth. 

The question has been much debated whether season favors the distribu- 
tion of diphtheria. Unquestionably the months of the winter are those in 
which the affection appears most frequently and most severely, and in which 
it attains its greatest distribution ; still there is frequently enough an oppor- 
tunity of observing the severest epidemics in summer, and I can still recollect 
with horror the first epidemics that I saw in the summer among the popu- 
lation of the country. However, it is possible that the affections of autumn 
and winter, particularly the catarrhal implication of the pharyngeal mucous 
membrane, produces a predisposition to the disease. 

The affection scarcely ever manifests a preference between rich and poor, 
and affects those living under the best hygienic conditions, even the members 
of royal families having succumbed to the malady. Naturally, the unfavorable 
mode of life of the poor, the bad housing, crowding together, and the unclean- 
liness which goes hand in hand with these, favor the distribution of the disease. 
However, it cannot be proven with certainty what was formerly generally 
accepted, that bad ventilation of rooms alone, or faults in flow of dirty water 
and gases from privies, favor the distribution of the disease. 

The affection occurs at any age and is widely distributed; the cases are 



734 DIPHTHERIA AND DIPHTHERITIC CROUP 

by no means rare in which parents are simultaneously attacked with their 
children, and in which the disease is frequently communicated to physicians 
from their little patients. Regardless of all this, the disease specially seeks the 
youthful and is most dangerous in them. According to our own observations, 
children in the first year of life are but seldom affected, but as early as in the 
second year quite large numbers are attacked; a maximum morbidity and 
also mortality figure is shown by the period from the second to the fifth year 
of life. This corresponds also to the observations of other investigators. They 
have not been able to determine that sex shows any difference in the predispo- 
sition to the disease, on the contrary, boys and girls are equally affected. Nei- 
ther do different constitutions show a variation in predisposition : but one point 
must be observed, that especially such children as suffer from chronic catarrh 
of the nasopharyngeal space, from enlarged tonsils and adenoid vegetations are 
attacked; also certain pre-existing affections produce an increased predisposi- 
tion, such as measles, and, above all chronic diseases, such as poliomyelitic 
paralyses, hemiplegias, etc. 

On the other hand, the very remarkable fact has been discovered that 
there are persons that are actually immune to the disease; and it is probable 
that this immunity is due to a peculiar constitution of the blood serum. 

As lias already been emphasized, the disease is contagious from person to 
person. The pathogenic organism, however, also adheres to fomites, such as 
clothes, toys, and may be transferred by means of them. But the transmission 
by this means occurs to a much slighter extent than by direct contact. Curi- 
ously, in spite of the daily experience regarding this contact-infection, there 
are some physicians who doubt this property, and just such instances have 
occurred in which physicians were infected, and these are more convincing 
than any others. Even Bretonneau mentions cases of this kind with a fatal 
outcome, and any physician of experience is able to relate some very dangerous 
examples of that period when it was not yet possible to take early and decisive 
measures against the disease. If in our practical activity, attention is paid 
to these points, we will note daily examples of transmission among children 
of the same family, school children, and from servants and nurses to chil- 
dren of the family. The most unpleasant and even momentous circumstance 
is this, that adults who do not appear to be seriously ill and only suffer from 
mild forms of angina may transmit the most severe forms of the disease to 
children. For example, some years ago my own child was infected by a servant 
who I ascertained afterward had visited her sister affected with diphtheria, 
the servant in question suffering from an angina which she had concealed 
from me. The cases are well known in which the further dissemination of 
the disease has been promoted by children affected with diphtheritic disease 
attending school. As slight as the transmission by fomites may be compared 
to the transmission by direct contact, this must, nevertheless, be admitted. 
We may assume as quite certain that transmission occurs by means of infected 
food products, milk, etc., although it may be difficult, in the individual case, 
to determine this mode of distribution of the disease. 



BACILLUS OF DIPHTHERIA 735 

How this transmission and dissemination occurs will be readily under- 
stood when we come to describe the cause of the disease, the bacillus of 
diphtheria. It is well known that after much fruitless and discouraging 
labor, after prolonged search, Loffler, in 1884, succeeded in cultivating a 
bacillus from the membranes of diphtheria, which had been previously noted 
by Klebs and described by him as the likely cause of the disease, but which 
still lacked an invariable demonstration, and for this reason was not fully 
proven. Loffler described the bacillus as a constant finding in the dense 
pseudo-membrane of typical cases of diphtheria; in small heaps below the 
surface of the pseudo-membranes where the bacilli are present in large num- 
bers they take an intense stain with the Loffler color-mixture. Loffler also 
gave the elective mode of cultivation upon a blood serum mixture, which 
since then has shown itself to be the best culture medium for the bacillus. 
The mixture consists of 3 parts of calf's or lamb's serum, 1 part of neutral- 
ized veal bouillon, 1 per cent, of peptone, 1 per cent, of grape sugar, and 
-J per cent, of table salt. The bacillus shows itself as a club-shaped organ- 
ism 1J to 2.0 microns long and 0.3 to 0.5 microns thick, usually as double 
rods so situated that they are joined at an angle (compare the illustrations, 
Figs. 33 and 34). In pure culture the microbes present a special appear- 
ance; the latter is somewhat characteristic in that the rods for the most part 
are parallel to one another, showing a palisade arrangement. 

I cannot enter here upon the other special peculiarities of the bacillus, 
nor upon the many and manifold doubts which were thrown upon it, espe- 
cially after a bacillus was discovered that resembled it, which was finally 
designated as the pseudo-diphtheria bacillus, which is, however, non-virulent, 
whereas the utmost virulence is a peculiarity of the diphtheria bacillus, and 
was proven in the most certain and convincing manner by Loffler in animal 
experiments. The diphtheria bacillus grows luxuriantly upon the slanting 
Loffler serum, in a few hours becoming microscopically visible, showing 
a pale, yellowish-green, vapor-like streak which appears finely granular 
upon the surface, or in wavy forms, with small roundish furrows upon the 
borders. 

What appeared to oppose Loffler's important findings was primarily the 
fact, that succeeding investigators did not always find the bacillus in all 
cases diagnosticated as diphtheria, until finally Eoux and Yersin in Paris 
demonstrated its presence in methodical examination, first in 61 certain cases 
of diphtheria, whereas in 19 others which originally had the appearance of 
diphtheria, but in their further course showed themselves as non-diphtheritic, 
is was absent. Simultaneously with the French authors, we began our own 
investigations in this hospital and we succeeded in demonstrating that the 
Loffler bacillus was always present in cases which showed a severe course, 
whereas those cases that were looked upon as diphtheria, but in which the 
bacillus was not present, showed an entirely different, i. e., more favorable 
course, a fact which was proven by all our further investigations. Hence 
we could say with absolute certainty that the Loffler bacillus, in the cases 



736 DIPHTHERIA AND DIPHTHERITIC CROUP 

admitted to this hospital in which a diagnosis of diphtheria had been made 
according to the clinical findings, was absent in scarcely 3 per cent., and in 
those cases in which upon repeated careful examinations the Loffler bacillus 
was not found, with but very isolated exceptions the clinical course showed 
that they were not cases of diphtheria. This assured the significance of the 
bacillus as the pathogenic agent of diphtheria and not the slightest contra- 
diction to this fact can be advanced, even to the present time, for the bacillus 
is found upon mucous membranes upon which no pseudo-membranes are 
present, and in which no actual symptoms of disease can be demonstrated. 
This latter fact, on the contrary, is connected with the immunity of the 
culture media in individual human beings, and no less so with the greatly 
varying virulence of the bacillus, which like all pathogenic bacteria without 
exception is very unstable and varies greatly; this, however, does not in any 
way alter the clinical facts that have been determined and they must be 
adhered to. 

I may assume that it is well known that the bacillus shows certain proper- 
ties which explain the manner of the distribution of the disease such as its 
extraordinary tenacity of life, how it flourishes in milk, how it adheres to 
fomites, such as under-clothing, boots, clothing, etc., further, its property of 
growth in association with streptococci, bacillus coli, bacillus proteus, etc., in 
which it has even been shown that some of the previously mentioned organ- 
isms are occasionally capable of increasing the symbiotic growth of the viru- 
lence of Loffler's bacillus, or to rekindle it. On the one hand, this explains 
the transmission of the disease by fomites, of which we have already spoken ; 
on the other hand, the upflaring of severe epidemics at one point and the 
milder course of the disease at another point. Let us consider for a moment 
the mode of action of the bacillus in the affected organism. Obviously, the 
pathogenic agent changes into a morbid condition the affected mucous mem- 
brane at the point of its attack, which process may be recognized in the 
appearance of the diphtheritic pseudo-membrane. What is this pseudo-mem- 
brane anatomically, and how does it arise? 

The anatomical changes in the mucous membranes which are attacked by 
the pathogenic agent and the pseudo-membranous formations have been for 
a long time the objects of closest observation, without complete unanimity of 
opinion having been attained even to-day. We cannot repeat in detail the 
various differing opinions, and I may refer, as I believe, to my rather exhaust- 
ive compilation in my book upon diphtheria and croup. 1 I can only repeat 
here that it is due to a high grade of degeneration of the vessels and fibrinoid 
degeneration of the connective tissue, causing a fibrinous exudation, the prod- 
ucts of which, upon the surface, are subject to necrosis and absorption, becom- 
ing a granular mass; with all this there is a dissemination of the entire 
new-formed mass, of the bacillus and other more accidental microbes (strepto- 
cocci, staphylococci, bacillus coli, etc.). Therefore, in a combination of 

i A. Baginsky. " Diphtherie und diphtheritischer Croup." Alfred Holder, Wien. 1898. 



TYPES OF DIPHTHERIA 737 

necrosis with exudative fibrinous desquamation, what is especially conspicuous 
is the extraordinarily great tendency to the propagation of the process, so 
that the membranes, as already described by Bretonneau, appear to " flow 
downward/' although they are tightly adherent and the mucous membrane 
is altered to some distance below the surface. 

The distribution of the process to the larynx, trachea and bronchi causes 
deposits in the respiratory tracts, producing suffocative phenomena and threat- 
ening death by choking. From the mechanical distribution of the process, 
however, the other severe symptoms and fatal cases that have nothing to do 
with suffocation cannot be explained. Here the second factor comes into 
play, that a severe active poison is produced at the point of action, entering 
the lymph and blood channels by osmosis and being conveyed by the blood 
and lymph streams to distant organs and tissues. Lofner in his first studies 
arrived at the opinion that the bacillus found by him produced a poison, and 
with this he explained the fact that the bacterium brought about intense 
general action in the affected or artificially affected organism. He also suc- 
ceeded in introducing the poison from precipitated glycerin extract of bouil- 
lon cultures by alcohol and he was able up to a certain degree to determine 
experimentally its deleterious effects. The French authors, Eoux and Yer- 
sin, went further, they discovered that the toxins elaborated from Loffler's 
bacterium brought about phenomena in animals which were throughout analo- 
gous to the severe diphtheritic symptoms in human beings; for example, 
certain forms of paralysis may be mentioned, the consideration of which we 
shall enter upon clinically somewhat more minutely. Eegarding the nature 
of this toxin, its probable chemical constitution, its terrible action on the 
animal organism, these cannot be discussed in detail here; it is sufficient to 
call attention to the fact that it has been carefully studied, and that espe- 
cially from these studies the wonderful knowledge of the antitoxic action 
upon the animal organism developed, which Behring utilized therapeutically 
in determining the antibodies which were secured from the blood. 

Upon the basis of the conclusions which we have reached, it is found that 
a priori the diphtheritic affections may be divided into two principal groups, 
first into that group of milder affections in which the author has been suc- 
cessful in limiting the area of the disease and rendering harmless the toxins 
produced at this point; these are the purely local diphtheritic affections, in 
which the general action of the poison does not occur. And then the second 
group, the general constitutional affections, in which the local limitation of 
the process is not successful, and the further distribution from the point 
of the first attack is rapid and marked, in which, above all, by the entrance 
of the toxins into the lymph and blood mass, severe and irreparable disturb- 
ances occur in distant organs. 

Limited, local diphtheria will always represent the mild, and general diph- 
theritic intoxication, with implication of distant organs, will include severe 
forms of the disease. By the term diphtheritis, the local limitation of the 
process is meant, by the term diphtheria the general involvement of the 



738 DIPHTHERIA AND DIPHTHERITIC CROUP 

organism is characterized, and we shall conform to this terminology, which 
I believe is very proper. 

Let us return to the histories of the two cases just quoted. It is not 
difficult to determine that in both cases we are dealing with forms of local 
diphtheritis. 

The further distribution of the process in the first patient is hardly likely, 
after the therapeutically protective prohibitive measures used by us; in the 
other case it may be excluded with certainty. We may expect that in the 
first case the membranes which are still present will soon loosen, will melt 
away, similar to the condition which has already occurred in the second case, 
without any deep lesions, ulcer formation or similar conditions remaining, 
also without general phenomena appearing later. In fact, these tissues are 
restored to complete health after a relatively short time, in from three to 
four to six days. Any one who has the fortune to observe only such cases 
of diphtheritic disease will hardly believe that the affection with which he is 
dealing belongs to the most terrible scourges of the human race. 

Is there then in any case of a locally appearing diphtheria from the onset 
the certainty of the local limitation of the process, and with this the fortunate 
undisturbed course of the disease ? As a rule, by no means ! During the time, 
which is now fortunately of the past, in which we were unable to make our 
patients " toxin-resisting," and to immunize them in time against the local 
effects of the poison, we were certain of no case, neither from the later propa- 
gation of the process to larynx and trachea, nor from the danger of suffoca- 
tive phenomena, nor from the appearance of severe later lesions, in particular 
severe cardiac phenomena, nephritis, and various forms of paralysis which 
often arose several days after complete sloughing of the membranes from 
pharynx and tonsils. For this reason the prognosis of the disease was very 
questionable, even in the apparently mild local forms, and this was true to a 
greater degree the longer the process continued, and the membranes remained 
upon the pharynx and tonsils. This has now fortunately become different, 
since it is possible to immunize the body with the serum of diphtheria if we 
use it in time and in sufficient quantity. Later, in describing the serum 
therapy we shall return to this consideration. However, at this place it must 
not be omitted that even without the action of serum, forms of the disease 
remaining local have occurred in every, even in very severe epidemics. Here 
the affected .organism was either able itself to produce protective bodies in 
sufficient amounts or it chanced that the microbes that brought about the local 
affection were not sufficiently virulent, so that this acute action of the toxins 
did not occur. However, I should advise not to depend upon such fortunate 
happenings in any single case; it is well to remember that no case, even 
though apparently mild, should be trusted. 

Tor this reason an active therapy is necessary in every case, no matter 
how mild. Generally in these local forms of disease a local therapy will be 
thought of. This is certainly not unjustified, and we shall learn to recognize 
a number of remedies which have the effect of combating the local lesion, 



SEPTICEMIC GENERAL AFFECTION 739 

that are commonly used and are b}" no means absolutely ineffective, even if 
they come far short of bringing about what was theoretically expected of them. 
We could here speak of these therapeutic effects, but I believe it is better to 
first describe general varieties of the diphtheritic disease and only then to 
speak of all therapeutic measures in connection. 

After having described the mildest local form of the disease, let us turn 
to the most severe, the septicemic general affection. This may be designated 
as a special division of diphtheria, and I shall describe a case from my former 
experiences, which, unfortunately, was rich enough in this respect. As a 
matter of fact, this is a terrible form of the disease, a form which has caused 
diphtheria to be the terror of entire nations, the specter of annihilation of 
entire families. Picture to yourself a waxy pale, swollen face, with a hollow 
glance, semicomatose, with open mouth, shrinking position of the body, the 
head deeply sunk into a pillow. The nose appears thickened, the nasal open- 
ings sore, and a yellowish irritating secretion is slowly seen oozing forth, 
which irritates the upper lip making it sore, red and thickened. The lips 
are dry, bloody, fissured. The entire anterior part of the throat appears 
unevenly thickened, and upon palpation the cervical lymph glands are felt to 
be enlarged to thick structures, which are not uniformly limited but changed 
into a general doughy swelling. The child snores, the eyes are half opened, 
the conjunctivae are visible, slightly injected, and the angles of the eyes usually 
somewhat purulent. A frightful fetor is noted in the respired air and almost 
forces us to remain away from the child. The tongue is red, dry, the papillae 
standing out prominently. The examination of the mouth, the tongue and 
the pharynx causes bleeding, which not infrequently is copious and difficult 
to control. The entire pharyngeal region presents an appearance which is 
actually terrible. Greenish-gray to black hemorrhagic masses clothe the phar- 
ynx, and nothing more is visible of a normal mucous membrane; the normal 
pharyngeal structures cannot be recognized. The velum palatinum is mark- 
edly thickened, and arising from it, reaching to both sides and anteriorly 
over the entire hard palate are seen thick, flattened, grayish-black pseudo- 
membranes. Usually the voice of the child is hoarse ; the cough which is due 
to the examination is hoarse, barking; the respiration is somewhat difficult, 
and, upon inspiration and expiration, slightly impeded without a conspicuous 
dyspnea being present on this account. 

The constitutional symptoms correspond to this terrible picture. Occa- 
sionally here and there upon the cutaneous surface, distributed petechias are 
found, or deeper-formed striae, hemorrhages which are distinguished from the 
surrounding intensely pale areas by a dark bluish-gray color. The pulse is 
feeble, can scarcely be felt at all, or is even absent; as a rule, however, it is 
accelerated, at the same time irregular ; the impulse is weak, the heart sounds 
dull; the belly is edematous; spleen and liver are enlarged; the urine mostly 
contains albumin; the bowels are constipated, and if a movement is brought 
about artificially it is of a very dark color and very offensive. The tempera- 
ture is but slightly raised, scarcely over 100.4° F., occasionally even sub- 



740 DIPHTHERIA AND DIPHTHERITIC CROUP 

normal. This is the condition that, as a rule, after two or three days leads 
to death. In the rare cases in which these septic forms of the disease ter- 
minate in recovery, this occurs by ulcerative sloughing of the gangrenous 
masses and a gradual cleansing of the many deep ulcers produced by this and 
not without severe general phenomena on the part of the heart, the kidneys 
and the nervous system, which we shall describe more in detail later on. 
Weeks and months may pass before such patients recover, and in some cases 
a persistent damage to the heart remains, which may still be noticeable for 
years and bring about the early death of the child. 

Let us examine the anatomical changes which are met with in autopsy of 
these severe cases. The pharyngeal structures show the picture of severe 
gangrene; deep into the mucous membrane a grayish-black coagulated and 
decomposed mass forces its way; the tonsils have almost disappeared, the 
deformed structures of the pharynx are scarcely recognizable; and over the 
thickened, tumorous epiglottis the same smeary grayish-black or greenish 
masses enter the larynx, leaving but portions of the true and false vocal cords 
recognizable. Below the arytenoid cartilage and the cricoid cartilage, looking 
into the trachea, over the dark red, here and there hemorrhagic mucous mem- 
brane, fine fatty structures representing thin membranes are noted, which 
fluctuate under a stream of water. The lungs are Iryperemic, partty atelec- 
tatic, partly filled with bronchopneumonic infiltrates. The liver is large and 
soft, the parenchyma is cloudy ; the spleen is also large, cloudy, less consistent, 
of a grayish, dull appearance, and upon the cut surface the follicles are hardly 
recognizable. In some cases special changes are shown by the stomach; 
the swollen and thickened mucous membranes show distributed, deep, dark 
brownish, hemorrhagic deposits in strise form, radiating from the cardia, and 
grayish-yellow deposits are noted in the centre of these stria?, which deeply 
penetrate into the hemorrhagic areas; occasionally the same changes are 
noted in the intestinal canal; as a usual thing Peyer's plaques are enlarged 
as in enteric fever, stand out prominently, are injected and even here and 
there hemorrhagic, or even ulcerated. An ugly gray cloudy appearance is 
noted in the musculature of the entire flaccid and dilated heart. There are 
also cases in which fresh coagula, which are adherent, apparently having 
arisen during life, can still be noted between the trabecule of the auricle or 
of the ventricle. All in all a typical picture of septic changes. The bacterio- 
logical examination of the fresh organs at autopsy allows us to cultivate the 
Loffler bacillus usually in combination with the streptococcus, whereas from 
the necrotic portions of the pharynx a rare mixture of bacteria is grown, 
among which the Loffler bacillus is naturally predominant. We see, there- 
fore, in this form of disease, besides the terrible action of the toxins of the 
bacillus in the region of its primary attack such as pharynx and nose, the 
phenomena of the general action of the virus in all organs, which may be 
recognized as the usual process, damaging the tissues in a most deleterious 
manner. 

The question has been much discussed, whether in the cases described, 



SEPTIC DIPHTHERIA 741 

the Loffler bacillus is the actual cause of these terrible changes or whether this 
action may be attributed to other microbes. The symbiosis with dangerous 
streptococci is certainly calculated to increase the virulence of the bacillus, 
nevertheless, there are enough cases to be observed in which in these changes 
the Loffler bacillus occurs in almost pure culture, so that, without doubt the 
most malignant lesions may be due to it alone. For this reason the designa- 
tion of these malignant septic forms as Diphtheric a Streptococque, which 
appears to be a favorite with French physicians, is not quite correct, it does 
not even require the presence of streptococci to bring about even the severest 
pathological phenomena ; a high grade of virulence of Loffler 's bacillus is alone 
sufficient, and for this reason this microorganism dominates this as well as 
the previously described pathological picture. 

Between this terrible affection and the previously described mild local 
forms, lie the other cases of diphtheritic general affection. Naturally, with 
serum therapy, as has already been mentioned, the clinical picture and course 
of the disease has changed so much that we only meet with these severe forms 
in cases that come under treatment very late, in which the virulence of the 
bacillus has been able to attain its full action. It will be well to look at 
the clinical history of some cases to illustrate this. 

Girl aged ten, taken ill eight days ago, showed lassitude, anorexia, and symptoms 
of general malaise. Four days ago she began to complain of throat pains, enlargement 
of glands noted on both sides of the neck; the child began to have a fetid breath, and 
evidently had high fever. Admitted to the hospital without having been treated by a 
physician. On admission, the first glance shows that we are dealing with a severely 
ill child. The face is pale, somewhat puffy. The sub-maxillary region swollen upon both 
sides. The glance is feeble, the entire musculature flaccid, the mind is clear; the voice 
is not hoarse, but only sounds suppressed, pharyngeal; the lips are dry, fissured. The 
tip of the tongue is dry, the superficial surface is covered with a grayish coating; the 
mucous membrane of the mouth is generally dry, only tough, pappy mucus adheres 
between the tongue and the palate. A serious picture is presented by the pharyngeal 
region. Both tonsils, the velum of the palate and the uvula are transformed into a 
greenish-gray thick pseudo-membranous mass. The uvula hangs like a rigid lump of 
a greenish-gray color upon the dorsum of the tongue; the enlarged tonsils almost meet 
in the median line, so that it is easy to understand the suppressed tone of the voice and 
the somewhat prolonged pharyngeal inspiratory murmur which is present. The gray 
membranous masses reach almost to the middle of the hard palate. The respiration is 
not actually hindered, but still it is irregular, about 20 to 25 respirations per minute. 
The pulse is bad, the wave low, the tension slight, 120 per minute. The cardiac sounds 
are very weak, dull; the size of the heart is normal in so far as can be ascertained by 
percussion, although the heart appears to be covered by the pulmonary borders. The 
temperature is 102.2° F. The urine contains much albumin; it also contains morphotic 
elements, cellular, somewhat decomposed substances and parts of casts. The rest of 
the organs show nothing abnormal. 

This represents one of the severe cases of general diphtheritic infection. 

Now let us observe the course which the disease ran in such cases, as a rule, during 
the period when we were not as yet in possession of a specific remedy, and which it 
may even pursue to-day if the remedy is only applied eight days after the beginning 
of the case, and its favorable action is not attained. Mostly, or at least in many 
such cases, the process which was present in the pharynx rapidly led to gangrene and 
the complete picture of sepsis developed, which we have described previously. Then 
the children sank more and more into a comatose condition and succumbed under the 



742 DIPHTHERIA AND DIPHTHERITIC CROUP 

phenomena of adynamia and cardiac collapse. With this the fever need not rise to 
high temperature ranges, nor need special complications develop. Or, and this is the 
better or the only course of the disease, the children began to improve, the pulse became 
better, and the albuminuria diminished; simultaneously, a reactive inflammation oc- 
curred in the pharynx, which prevented the membranes from spreading and produced 
desquamation at the margins of the pseudo-membranes. This gradually caused the 
membranes to loosen by disintegration, and after three to four to six days it could be 
noted that the pharynx had become free, the swelling had diminished, the red mucous 
membrane of the velum and the tonsils again appearing. With this, the entire condi- 
tion of the child had improved; the lips no longer were so fissured, the tongue no longer 
so dry as formerly, the fever had declined. Convalescence began and uninterruptedly 
ran its course. 

However, this was the rarer case. More frequently, only during this time, 
those threatening and dangerous morbid phenomena occurred which pointed 
to severe damage to internal organs, the heart, the kidneys and the nervous 
system. What characterizes the course of these diseases now since we have 
employed serum treatment is this, that what was previously the exception is 
now the rule, that, usually, with the desquamation of the pharyngeal coatings, 
the decrease of the swelling of the mucous membrane occurs, and with it 
complete euphoria. Naturally, only then if not too long a period intervenes 
between the onset of the disease and the employment of the remedy. 

Still a third course is open to these cases, i. e., the further distribution of 
the pseudo-membranous masses to the larynx and trachea, and with severe 
suffocation threatening life, the phenomena of diphtheritic croup appear, which 
require prompt surgical interference. 

All of these methods of termination we shall now have to study. The}' 
may be studied in those cases which, although treated with curative serum, 
did not remain free from complications, because the employment of the remed} T 
was too late or it was used in insufficient amounts. 

This can be studied from case histories in which diphtheritic cardiac 
symptoms are very characteristically shown as the expression of a lesion of 
the heart. 

Girl aged four years; upon the fourth day of her disease became markedly worse 
and was brought to the hospital. The child was well nourished but was cyanotic from 
the onset. The voice was clear, not hoarse, dyspnea was not present. The pulse was 
small and easily compressible, 138 beats per minute, the temperature was 101.8° F. 
Small quantities of a mucoid secretion flowed from the nose. The pharynx was mark- 
edly swollen, the vault of the pharynx, uvula, tonsils and posterior pharyngeal wall 
were completely covered by a smeary, gray, quite thick, pseudo-membranous mass; 
there was fetor ex ore that was quite unpleasant. The heart showed nothing abnormal ; 
especially were the heart sounds clear. Lungs normal. The urine was of acid reaction, 
contained moderate quantities of albumin, and showed, among morphotic constituents, 
swollen and partly degenerated, granular as well as epithelial cells, containing fat 
granules, also hyaline casts covered by cells and granules. The further course of the 
affection was completely free from fever, the membranes loosened slowly. During the 
entire time, in spite of the apparent euphoria, it was conspicuous that a certain coolness 
of the extremities was present, with a small, easily compressible pulse, varying between 
118 and 140 beats per minute. Upon the eleventh day of the disease a slight paralysis 
of the velum of the palate was noticed, and, apart from the somewhat nasal voice which 
still existed for some time, was easily recognized by the fact that fluids that were taken 



ANATOMICAL CHANGES 743 

easily caused paroxysms of coughing and choking and were also regurgitated through 
the nose, In the meantime the heart-sounds had become peculiarly dull, and it was 
noticed in the radial pulse that an intermission of some beats occurred from time to 
time, this giving the pulse a certain degree of arrhythmia. Up to this time the albumin 
had not entirely disappeared from the urine. If the heart in this stage is examined it 
will be noticed that the impulse is weak, scarcely to be felt, percussion of the borders 
of the heart is not changed, but auscultation shows a peculiar character of the heart 
sounds which has been designated galloping rhythm. This is a peculiar beat of the 
heart showing three beats, not always with the same accentuation of the sounds, usually 
so that the principal accent occurs upon the first beat, but also that the second among 
the three beats, therefore, the middle tone, is principally accentuated. This peculiar 
rhythm appears to arise in that the ventricular contraction occurs in two different 
periods; it is especially then a certain sign of severe disturbance of cardiac action and 
weakness of the heart muscle if it is not quite rhythmical. This phenomenon is always 
very important and requires the greatest attention, as it not rarely indicates beginning 
destruction of the heart muscle, perhaps also of the cardiac ganglia, and is thus the 
first sign of a beginning fatal issue due to the heart. Fortunately, this is not always 
the case, and in the history just quoted it is possible that the little patient will recover 
and go on to complete convalescence. 

However, we must not conceal the fact that the condition is very dangerous, espe- 
cially if we recollect the sad results which under similar conditions have occurred too 
frequently. Under like circumstances,, as in the case just quoted, cardiac death has 
occurred, it being impossible to prevent this issue. It may take place in two different 
ways: In the midst of apparent euphoria, suddenly vomiting may occur and a very 
serious condition of collapse take place, which rapidly and quite suddenly leads to 
death; then the pulse disappears suddenly from the radial artery, the child becomes 
remarkably cyanotic, and later on pale. The extremities, the tip of the nose, are 
cold; the respiration irregular and may become stertorous, and in spite of all analep- 
tics, the child dies in the arms of the nurse. Or death due to the heart may occur 
slowly, but is just as certain, in that varying collapse-like conditions and the adynamic 
phenomena finally increase. In the latter case paralyses are usually present and the 
kidneys are affected; with vomiting, difficulty in respiration, severe abdominal pains 
occur. The lips are pale and cyanotic. The extremities are cold, the pulse can scarcely 
be felt, thready. The cardiac impulse is weak, minimal, tachycardia is present, so 
that up to 200 rapid and irregular contractions occur in a minute; or the cardiac 
contraction becomes increasingly more sluggish and slower, 36 to 40 beats in a min- 
ute. Vomiting occurs more frequently, briefer pauses of improvement intervening, 
which give fresh hope. However, the collapse phenomena return, simultaneously the 
liver enlarges, becoming larger and larger, and may be palpated as a large stone-hard 
tumor, reaching down into the pelvis. The child has become apathetic to the highest 
degree, the eyes have a glassy look, the tongue and the tip of the nose have become 
cold; respiration is weak, scarcely perceptible. Tired, exhausted almost to the point 
of death, sometimes with a completely clear mind, it turns upon the side and gently 
slumbers without producing a sound, never to awaken again. Involuntarily, even if 
it were not known, the physician and all those surrounding the patient recognize the 
action of a terrible poison, which apparently has shown its action by paralyzing the 
heart muscle. 

If we ask ourselves what anatomical changes the heart muscle in these 
conditions and processes has suffered, we would be greatly mistaken if we 
assumed that they are always very marked or constantly of the same nature. 
Occasionally, in fact, nothing is found which could at all explain the loss in 
the action of the heart, and this is especially the case if death has occurred 
quite rapidly. In these cases, probably lesions of the cardiac nerves and gan- 
glia arise, which can only be demonstrated with the greatest difficulty. On the 



744 DIPHTHERIA AND DIPHTHERITIC CROUP 

other hand, however, there is found, especially in those cases in which the 
agony has lasted for some time, and in which improved conditions have varied 
with renewed collapse, the grossest changes in the heart muscle, fatty degen- 
eration of the almost complete muscular structure, gross changes in the nuclei 
of the muscles, and complete fragmentation or hemorrhagic dissemination of 
the muscular tissue and with this adhering thrombi which have most probably 
occurred during life. 

But it is not the heart alone that is endangered ; the kidneys are no less 
affected, as may be noted from the appearance of marked albuminuria and 
the morphotic constituents in the urine. It is well known that scarcely any 
case of severe diphtheritic infection runs its course without pathological im- 
plication of the kidneys, so that, for example, Aufrecht has reached the con- 
viction that the disease of the kidneys and the plugging of the uriniferous 
tubules by shreds of tissue, as the result of parenchymatous changes, represent 
the primary condition of the severe symptom-complex, the heart being simul- 
taneously affected. This may be true of a number of cases, but certainly not 
of all of them, as the renal affection and the cardiac implication may run their 
course independently of each other, a condition that I have observed in numer- 
ous cases. In this we must certainly agree with Aufrecht that the severest 
cases are mostly those in which cardiac phenomena simultaneously run their 
course with pathologic urinary changes, and that the presence of large quan- 
tities of albumin in the urine, and, above all, the finding of certain morphotic 
constituents, makes the prognosis of the cases decidedly more unfavorable. 
The presence of numerous peculiar, coarsely granular, changed, refractive, 
decomposed epithelial, cell masses in the urine for a long time has been the 
sign of an especially unfavorable prognosis. We hardly know what to think 
when these severe diphtheritic renal changes, which were described long prior 
to the introduction of serum therapy, are now ascribed to the employment 
of serum. 

The renal affection also shows itself clinically by a diminution in the 
amount of urine and is especially characterized in that but few, individual 
cases excepted, marked renal hemorrhages occur in diphtheritic affection, in 
contrast to the renal inflammations occurring in scarlatina, in which the 
occurrence of blood in the urine is one of the most important clinical mani- 
festations of the disease. The diphtheritic renal affection is further charac- 
terized by the very rare occurrence of dropsy and the uremic symptom-com- 
plex. The latter condition probably does not arise, in that in severe forms of 
diphtheria which have not received proper treatment the deadly toxins of the 
organism caused by the diphtheritic virus develop more rapidly than the 
picture of uremia with convulsions and coma. 

The anatomical changes which are the foundation of the clinical symptoms 
of the renal condition have been carefully studied and it has been shown that 
they are due to a true toxic destruction of the kidney in which the macroscop- 
ical finding varies greatly. Sometimes the kidneys are hyperemic, enlarged 
and soft, at other times they are anemic, or the hyperemia is limited to the 



DIPHTHERITIC PARALYSIS 745 

medullary substance which may assume a bluish-black appearance; often a 
moderate distribution of the cortical substance, with a reddish-gray or more 
grayish-white or finally yellowish discoloration of the same is noted. Micro- 
scopically, all stages of degenerative change of the epithelia, cloudy swelling, 
vacuolar degeneration, necrosis and fatty degeneration is seen in the kidney, 
so that the nuclear staining property in many areas has been completely lost. 
What is especially conspicuous, in contrast to the scarlatinal renal changes, is 
the focal necrosis of the epithelia. There are also found, peculiar net-like 
mass-arrangements of colloid substances in the region of the urinary tubules, 
thickening and proliferation of the epithelium of Bowman's capsule and loss 
and disappearance of the glomerular loops, so that, in fact, all portions of 
the tissue of the kidney are implicated in the malignant process. 

We have thus seen two organs affected in a deleterious manner by the 
influence of the diphtheritic virus, but we still meet certain phenomena in the 
clinical picture which cause us to devote some attention to a third organ, to 
the nervous system. 

In the clinical history just communicated, we have already met with a 
peculiar paralysis of the velum of the palate and a paralysis of deglutition. 
I shall relate the history of another little patient aged four years, that showed 
the phenomena of diphtheritic paralysis to a much greater extent than the 
one whose history was previously related. 

The child is treated upon the fourth day of the disease, but already shows 
a very markedly developed laryngeal stenosis, widely distributed diphtheritic 
coating of the entire pharynx, tonsils, uvula, and velum palatinum. The 
child, that had high fever, shortly after admission, had to be intubated, simul- 
taneously after 3,000 antitoxin units of Behring's curative serum had been 
employed. The course was not favorable in the first days of observation, as 
a distressing cough constantly forced the tube out and intubation had to be 
repeated several times; the fever also continued, with temperature between 
100.4° F. and 102.2° F., with quite a rapid pulse, up to 150 beats per minute. 
Marked fetor was present in the child from the onset, and the loosening and 
destruction of the membrane occurred but slowly and with great difficulty; 
severe diphtheritic rhinitis, otitis media, with a purulent flow, bronchopneu- 
monic symptoms, complicated the clinical picture; with this there was albu- 
minuria and the signs of cardiac weakness, the latter showing itself with a 
poor and weak pulse. In this case, as in the other, upon the eleventh day of 
observation in the hospital, the first signs of paralysis appeared in the form of 
difficulty in deglutition. Fluid produced cough, and was regurgitated from 
the nose ; at the same time marked diminution of the patellar reflex appeared. 
These phenomena developed further and the difficulty in deglutition, simul- 
taneously with newly appearing marked phenomena of stenosis of the larynx, 
compelled us, finally, to desist from renewing intubation, and to perform 
tracheotomy. After that the fluid could no longer be swallowed, the little 
patient was nourished three or four times daily with the stomach tube. The 
following was then noted : The child was very weak ;' there was still quite high 



746 DIPHTHERIA AND DIPHTHERITIC CROUP 

fever, and the lungs were not quite free, showing the seat of bronchopneu- 
monia areas. Above all, upon observing the child closely, it is noted that the 
angle of the mouth on both sides droops flaccidly, which gives the face a 
peculiarly relaxed expression; apparently both facial nerves are paralyzed, 
and with this there is bilateral ptosis, somewhat more marked on the right 
side than upon the left, and the pupils will not respond to light; apparently 
bilateral oculo-motor paralysis is present. Whether both sixth nerves are 
paralyzed cannot be determined, as the child does not clearly perceive light. 
Further, the velum of the palate is rigid; the difficulty in deglutition has 
already been referred to. If an attempt is made to raise the child to a sitting 
posture it collapses so that a well-developed paralysis of the extensor muscles 
of the back must be assumed. The abdominal reflexes are absent, as well as 
the patella tendon reflex and the phenomenon of the Achillo-tendon. What is, 
however, more conspicuous than anything else is the peculiar, helpless manner 
of coughing, and the difficult, hindered respiration, although the cannula is 
quite free, this is due apparently to an insufficiency of the entire musculature 
of respiration including the diaphragm. How dangerous this serious condition 
of the poor patient is, need scarcely be emphasized. It is evident that death 
may occur at any moment by suffocation caused by paralysis of the muscles 
of respiration, to which cardiac paralysis may be very readily added. Fortu- 
nately, these very well distributed paralyses are rare, they were even rare 
prior to the employment of serum treatment; since the introduction of the 
same, cases of paralysis of this extent are quite exceptional, and in the last 
few years, as far as my experience extends, this is the only case of the kind 
that I have noticed. 

Let us continue the discussion of these forms of paralysis. 

Two principal groups may be differentiated : First, the early paralyses, 
which are almost always seen in the severest, usually in the septic cases, or 
in morbid conditions which are closely allied to sepsis. The paralysis always 
begins in the velum of the palate, and is accompanied by prostration of the 
entire organism, and severe adynamic-cardiac conditions. The cases are mostly 
fatal. The second group includes the late paralyses, which have also been 
designated as post-diphtheritic. These occur two to three weeks, even five to 
six weeks after the onset of the diphtheritic affection. Here also the paralysis 
begins mostly in the velum of the palate so that speech becomes nasal and 
deglutition difficult; nevertheless, frequently as a first phenomenon, the ab- 
sence of the patella reflex is noted, occasionally after an increase had existed 
some days previously. From this point the paralyses advance with a certain 
irregularity, however, in the manner that paralysis of the eye-muscles, paraly- 
sis of accommodation, also frequently facial paralysis arise relatively fre- 
quently, whereas paralysis of the musculature of the trunk and even of the 
respiratory muscles, especially of the diaphragm, belong to the rarest forms 
of paralysis. Excellent descriptions of these forms of paralysis are found in 
medical literature; there are the communications of Maingault, Donders, 
Duchenne, above all, the excellent self-observation of Hansemann, perhaps 



COMPLICATIONS OF DIPHTHERIA 747 

also the collection of the observations made by myself in my book that has 
been frequently quoted. The paralysis may also include the sensory nerves, so 
that anesthesia and paresthesia may accompany the motor paralysis : the sym- 
pathetic system may also be affected so that paralysis of the musculature of 
the intestines and bladder may be observed. 

The anatomical basis .of these paralyses is formed partly by neuritic changes 
in the peripheral nerves (toxic neuritis), partly they may be due to central 
processes. Severe anatomical lesions of the ganglia have lately been described 
on several occasions. I should not like to enter upon a discussion of these 
conditions as they have not as yet been definitely settled. 

Still a special variety of paralysis should be mentioned which has actually 
nothing to do with the post-diphtheritic paralysis and is rarely observed, but 
which should, nevertheless, be recognized, these are hemiplegic paralyses. 

We have had an opportunity of noting three such cases. The paralysis may 
occur suddenly and may throughout take on the character of an apoplectic 
attack ; it is of a well developed hemiplegic character. As an anatomical basis, 
an embolic affection in the corpus striatum or also a circumscribed hemorrhagic 
encephalitis has been determined. Here, therefore, the point of origin is not 
the nervous system but the vascular system. Apparently at one time the ex- 
pression of the severe alteration of the blood mass by toxic substances circu- 
lating in the blood, that give rise to coagulation and, further, the adynamia 
of the cardiac action which goes hand in hand with the destruction of the 
heart muscle, which, finally, causes clot-formation in the heart or in the ves- 
sels. 

We have now learned to recognize serious changes of organs which are due 
to the toxic substances which have entered the circulation that are produced 
by Loffler's bacillus, however, we dare not close our eyes to other affections 
which, although they are not specifically peculiar to diphtheria, nevertheless, 
are of the greatest importance to the entire course of the disease. To this the 
bronchopneumonias must be mentioned which accompany the difficult pharyn- 
geal affections, also intestinal disease with malignant diarrhea; further, the 
phlegmonous lymphadenitis of the neck, otitis media purulenta, occasionally 
with an implication of the bone of the mastoid process and even of the internal 
ear; further, secondary peritracheal abscesses, abscesses of the mediastinum, 
etc. ; they have all been observed by us, they all may have contributed toward 
bringing about the fatal issue to the toxically influenced and severely impli- 
cated organism. We cannot at this place enter more fully into these compli- 
cations. With proper treatment instituted at the right time, they will be but 
rarely observed. 

We must, however, acquaint ourselves minutely with the very frequent 
and very readily appearing implication of the upper air passages, the nose, 
the larynx, the trachea and the bronchi in the diphtheritic process, and the 
suffocative phenomena, the phenomena of diphtheritic croup, which are due 
to this implication. I have already called attention to the diphtheritic disease 
of the nose in some of the case histories that I have related; I have also 



748 DIPHTHERIA AND DIPHTHERITIC CROUP 

described an ugly, sero-fluid secretion, which, as I said, excoriates the upper 
lip, making it sore and causing swelling. If the nose is more carefully exam- 
ined in such cases pseudo-membranous coatings of the exact anatomical char- 
acter of true diphtheritic membrane are met with anteriorly in the neighbor- 
hood of the nasal openings; however, if this is not the case the process may, 
nevertheless, be designated as diphtheritic, as the secretion contains the diph- 
theria bacillus in plentiful amounts. This may be determined by a simple 
dry preparation, and in cases in which the investigation is negative, a culture 
will decide in a few hours. It should be constantly borne in mind that every 
light-yellow, fluid, irritating nasal secretion which excoriates the margins of 
the nose and the lips is suspicious of diphtheria; these phenomena should be 
borne in mind ; then it will not occur as it has so often with physicians, that 
after this condition has been present for some days and the affection has been 
looked upon as a simple cor} r za, suddenly they have been surprised by severe 
suffocative laryngeal symptoms of a croupous nature in children, unfortu- 
nately at a time when it was too late to use effective measures, and when even 
from serum treatment and tracheotomy they could not hope for relief. This 
is especially the case in small children, in nurslings, and then latent or larval 
diphtheria is spoken of; however, those who understand these conditions see 
nothing latent or larval in them. 

At this point I shall mention those forms of pseudo-membranous rhinitis 
in which croup membranes line the entire nasal cavity, so that they may be 
removed in large pieces with a syringe or forceps. For the most part they 
run a more chronic course, and this morbid process only rarely or scarcely 
ever implicates the pharynx or even the larynx, and, nevertheless, in these 
membranes and in the nasal secretions, Loffler bacilli have been repeatedly 
demonstrated. Apparently, in this instance the condition is due to a much 
less virulent form of disease, which runs a subacute or chronic course, being 
purely local ; nevertheless, I should like to insist on the need of care even here, 
and the exercise of all the caution in prophylaxis and therapy usual in the case 
of true diphtheria so as not to be surprised by more serious developments. It 
is well known that Cadet de Gassicourt has described similar, more chronic, 
local diphtheritic affections also in the pharynx, and we have had an oppor- 
tunity of seeing them frequently, even some years since. Xot very rarely 
diphtheria begins, and at that in its severest form, with an affection of the 
nose, and prior to the period of serum therapy the not quite unjustified 
assumption was prevalent that particularly these varieties of the disease were 
the most dangerous. This naturally does not always happen now, although it 
is true that the septic forms of diphtheria also for the most part implicate the 
nose. 

By far the most dangerous symptoms are those which arise from the larynx, 
and every physician who is familiar with the true croupous diphtheritic laryn- 
geal symptoms will certainly, no matter how experienced, feel anxiety if these 
symptoms appear in a child under treatment, or increase in severity. The 
most marked characteristic of this form of the disease is hoarseness of the 



PSEUDO-CROUP 749 

voice, the barking, dry, hoarse cough, and the long-drawn, almost hissing or 
sawing, inspiratory and expiratory respiratory murmur. It is certainly not 
always necessary, even if true diphtheritic membranes are detected in the 
pharynx, to assume diphtheritic disease of the larynx on account of the hoarse 
voice and barking cough, for these phenomena may also occur in catarrhal 
laryngitis ; it is a well known fact that a very acute catarrhal laryngitis occurs 
where there is no sign of diphtheritic disease, and with the same symptoms, 
without seriously threatening the life of the affected child by suffocation, and 
for this reason the name pseudo-croup has been given to the condition. Never- 
theless, we will have every reason to look upon hoarseness in a well-defined 
diphtheritic laryngeal affection with the greatest suspicion and care, and, even 
in those cases where the pharynx is found completely free, it is considered 
good practice, either by bacteriological cultural investigation of the laryngeal 
and pharyngeal mucous membranes or by laryngoscopic examination, to de- 
termine that the larynx is free of pseudo-membranes; for there are cases 
enough in which the formation upon the tonsils and pharyngeal mucous mem- 
brane is only slight or in which the pseudo-membranous masses have entirely 
disappeared from these areas, only then the actual diphtheritic laryngitis 
appearing. As a rule, diphtheritic laryngitis begins in a period when pseudo- 
membranes are still demonstrable in the pharynx, so that the laryngitis arises 
as a result of the descent of the pseudo-membranes from the pharynx to the 
larynx, and Bretonneau has spoken of these downflowing masses. If the diph- 
theritic laryngitis develops slowly, the voice gradually becomes hoarse and 
there is heard, besides, a rough scraping tone accompanying the inspiratory 
prolongation of the respiration, a less prolonged audible expiration. As a 
rule, the children have fever, which occasionally reaches high ranges, and now 
in a relatively brief time, the affection develops more and more to the clinical 
picture which I shall describe in the following clinical history. 

Small boy, aged two, taken ill five days previous. It was noted that the boy was 
well nourished, but, nevertheless, his appearance upon admission showed that he was 
very ill. The face had an anxious expression; the eyes were widely opened, the alae 
of the nose dilated with each respiration during which the mouth was open; simultane- 
ously we noted that with each of the long piping, hissing, respiratory movements the 
jugular vein became more prominent — also that the thorax, with the assistance of all 
the inspiratory muscles, the sternocleido, and the pectoral muscles, was markedly 
raised; we also noted how, upon inspiration, the intercostal spaces were drawn in, a 
deep furrow forming at the lower border of the thorax, the scrobiculus cordis sinking 
in deeply and great dyspnea being present. Apparently, there was not sufficient air 
in the lungs, so that the intercostal spaces and the other soft parts surrounding the 
thorax sank in on account of the external pressure of air. We noted the sawing, pro- 
longed inspiration, and the hoarse, creaking, barking tone of the cough; with this 
there was complete aphonia. A glance into the pharynx by no means showed very 
extended membranes, we were only able to recognize upon the swollen tonsils some 
grayish-yellow spots and streaks and similar ones perhaps somewhat thicker upon the 
posterior mucous membrane of the pharyngeal wall. Nevertheless, we could not doubt 
that we were dealing with true diphtheritic croup and it was necessary to relieve the 
respiratory difficulty, and that as rapidly as possible. In the first place we noted the 
anxiety of the child, and then the tense radial artery, the hard pulse, the cyanotic condi- 
tion of the lips, and also the somewhat livid color of the face, these showing us that the 



750 DIPHTHERIA AND DIPHTHERITIC CROUP 

child was nigh unto suffocation and required speedy help. We intubated at once, but 
we had everything in readiness for tracheotomy in the case of this small child, meaning 
immediately to proceed to tracheotomy in case of failure of the intubation. 

What would have happened to this child if we had not relieved it in the 
manner we have just indicated ? Without doubt, the dyspnea would have in- 
creased, the respiration would have become deeper and more labored, and, 
assuredly, we should have seen the child tortured with the terrible phenomena 
of suffocation, raising itself as much as its strength would allow, fighting for 
air, with a livid, cyanotic face, blue lips, covered with perspiration, with cold, 
moist extremities. Perhaps under the influence of these very great exertions 
the respiration might have quieted itself somewhat; it would have become 
somewhat freer if the child had succeeded in bringing up some mucus or even 
some shreds of membrane with the severe coughing. Then the child would 
have collapsed in its bed and slumbered for a brief time; soon, however, the 
attacks of suffocation would have repeated themselves and the same phenom- 
ena would have returned, but not for a long time. The powers are weakened ; 
the child now remains quiet, in apparent slumber, longer and longer, the lips 
and the color of the body become more bluish, the respiration apparently 
becomes freer, less audible, less sawing and hissing, the cough desists com- 
pletely; however, if we examine accurately, we note only a very superficial, 
no longer complete respiration. The mind is apparently no longer free, the 
child is in a comatose condition, from which it no longer awakens, but slowly 
slumbers into the condition from which there is no awakening. This would 
be the infallible, unalterable termination which, according to our experience, 
neither internal nor external remedies would be able to ward off. And because 
we knew this we did not hesitate one moment to interfere. 

And the cause of this terrible onward course ? A glance into the jars con- 
taining anatomical preparations of pseudo-membranes in the larynx is suffi- 
cient to explain this. It will be noted how a thick pseudo-membranous mass 
plasters the entire larynx, completely closing the rima glottidis, and how 
thence a thick, tube-like, formed and compact pseudo-membrane fills the en- 
tire trachea, entering through the bronchi, through the smallest and finest 
bronchioles, even coating them for wide areas. With this it can be seen that 
the lungs have collapsed, are thickened, and partly, especially around the bor- 
ders, markedly dilated, resembling emphysema. This is, therefore, the anatom- 
ical finding of diphtheritic croupous laryngo-tracheo-bronchitis; this dreadful 
disease is almost invariably fatal, provided we do not succeed in bringing help 
to the suffering child by means of mechanical and specific remedial measures. 
Here, therefore, there is added to the toxic infectious process of diphtheria, a 
mechanical condition which brings about death by suffocation. Now we can 
understand why the ancient physicians spoke of synanche, garotillo, of stryps- 
juka, etc. In fact, of all the dangers of diphtheria that we have learned to 
recognize up to now, the danger of suffocation, due to the descending croup, 
is the greatest, and to be all the more feared because it is a daily frequent 
danger. 



MIXED INFECTIONS 751 

Let us devote a few words to some of the symptomatic peculiarities of the 
clinical picture of croup. 

We have laid stress upon the aphonia; this symptom is almost always 
present, but it may be absent, provided the larynx is free from membrane in 
the region of the vocal cords, more free than the trachea and the bronchi; 
therefore, the presence of the voice by no means excludes diphtheritic croup; 
and these cases, as a rule, are the most dangerous because the diphtheritic 
exudation and necrosis have invaded the parenchyma of the lungs more deeply. 
The pulse, further, requires consideration. For some time attention has been 
paid to this, and especially to the beginning retardation of the pulse, its slow- 
ing with the advancing asphyxia, and pulsus paradoxus described by Kuss- 
maul; the phenomenon that causes the pulse to disappear more and more 
during the long-drawn inspiration has been looked upon as a valuable sign. 
It is not easy to demonstrate this in the restless child that constantly throws 
itself about ; but it may be distinguished if some attention is paid to this point. 
In cases in which this phenomenon can be noted, a very severe disturbance of 
respiration may be concluded, and we should keep ourselves in readiness to 
immediately combat the dyspnea, because the children are threatened by the 
danger of suffocation. Not so constant are the signs of the disturbance of 
circulation in the urine, such as the presence of albumin, or of blood, or a 
diminution in the amount of urine. In the moment of greatest danger to 
life they are not to be accorded too great value. 

I have now called attention to the most important phenomena of the 
diphtheritic process; I have as yet not spoken of the various localizations of 
the diphtheritic process at other points, i. e., the diphtheritic cutaneous affec- 
tions which appear particularly in areas that are the seat of eczema, that belong 
to the ugliest and most painful forms of disease, as they enter deeply into 
the skin from the subcutaneous tissue, causing necrosis and leading to sepsis, 
then, for example, giving rise to the disturbances which have been designated 
dermato-myositic, which bring about an icteroid condition of the muscle fibers 
and belong to the most serious processes that are observed; further, the diph- 
theritic disease of the genitalia, especially in little girls; they resemble those 
of the external auditory meatus and of the middle ear and the conjunctival 
sacs. These severe lesions are noted in widely distributed diphtheria epidem- 
ics, especially among a class of the population that live under bad unhygienic 
conditions. I have as yet not spoken of mixed infections of diphtheria, of the 
serious combinations of diphtheria with measles, scarlatina, whooping cough 
and other diseases. It is readily understood that on account of the toxicity of 
the diphtheritic process all these combinations are of the most serious im- 
port, and prior to the introduction of serum therapy every one of these compli- 
cations had greatly increased the mortality among sick children. 

These conditions have all improved, although we must not conceal the 
fact that the danger to children, even under the influence of this powerful 
active remedy still requires the most watchful care and the most profound 
knowledge. 



752 DIPHTHERIA AND DIPHTHERITIC CROUP 



PROGNOSIS 

This leads us to the question of the prognosis of the disease. Briefly ex- 
pressed, every phase of diphtheria, no matter how mild, is to be taken seri- 
ously, as well for the patient himself, as also on account of the danger of 
transmission to those about him. However, we must take into consider- 
ation that there are in fact dangerous, and less dangerous epidemics, and that 
the mortality of the disease is subject to many spontaneous variations. Only, 
we must not depend upon the mildness of an epidemic in an individual case ; 
this might easily lead to very evil consequences. 

In general I may state the following regarding the prognosis: The prog- 
nosis is the more unfavorable, the more diffuse the local process, the more the 
pseudo-membranous deposits cover the entire pharynx, especially distributing 
themselves to the hard palate, the more smeary the membranes appear, the 
worse their color and the less localized. Naturally, the implication of the 
larynx, with stenotic phenomena renders the prognosis decidedly worse; signs 
of general sepsis, such as marked fetor, diffuse swelling of the submaxillary 
and post-cervical lymph glands and, finally, hemorrhages from the pseudo- 
membranes, hemorrhages from the mouth and nose as well as petechia?, are 
calculated to render the prognosis grave. With all these phenomena the prog- 
nosis becomes the worse, the later the proper antitoxin serum therapy is 
employed after the onset of the affection. 

That the prognosis has become entirely different since the introduction 
of serum therapy, which has been so frequently mentioned by me, and that 
by means of this remedy we have obtained a factor which ensures certainty 
beyond our wildest hopes in prophylaxis and in the therapy of the disease, will 
already have been recognized from my previous remarks. This subject will be 
entered upon more in detail later. 

DIAGNOSIS 

First I shall devote a little attention to the diagnosis of the disease. We 
might expect that in a disease which is so characteristically developed as a 
pseudo-membranous affection of the pharynx or of the pseudo-membranous 
process in the larynx, running its course with dyspnea and signs of suffocation, 
the diagnosis could not be mistaken. This is true up to a certain degree, 
and an experienced practitioner who has cultivated the art of inspection will 
only rarely fall into error or even be placed in a position of doubt. In 
fact, the clinical finding of the grayish-yellow, or grayish-green, thick, mem- 
branous deposits upon and in the pharyngeal tissues, for the most part 
decides the diagnosis. How certain this is, may best be seen from the fact 
that in our hospital the decision of transferring patients into the diphtheria 
division occurs principally from the clinical findings, and I might say. almost 
never has a case been looked upon by us as diphtheria and brought into the 



DIAGNOSIS 



753 



pavilion in which only diphtheria patients are accepted that was not proven 
by a later bacteriological investigation to have true diphtheria. Nevertheless, 
we must not conceal the fact that there are also obscure cases, cases of well- 
developed follicular angina that give rise to doubt, and these cases require the 
bacteriological determination of the Loffler bacillus. The bacteriological exam- 
ination decides the diagnosis for these cases, which we place in a separate 
division. Not as if the presence of diphtheria bacilli without a determinable 
disease of the pharyngeal membrane or the nasal membrane or of the larynx 
could and would decide us in favor of the diagnosis of diphtheria, but we may 
be certain of the fact that apparently healthy persons, also children, may carry 
diphtheria bacilli around with them. These persons are dangerous to others 
on account of contagion, but they are 
not diphtheria patients themselves. 
On the other hand, that individual is 
affected by diphtheria who has the 
combination of an angenoid mucous 
membrane infiltration or even of a 
pseudo-membranous membrane coat- 
ing in the nose, in the larynx or in 
the trachea, in which the Loffler ba- 
cillus may be microscopically deter- 
mined or can be recognized in cul- 
ture. On the other hand, of those 
that show similar morbid conditions, 
in whom the demonstration of the 
Loffler bacillus is not possible, it may 
be declared with great probability, 
almost certainty, that they are not ill 
of diphtheria. The course of these 

latter affections that are mostly due to staphylococci and streptococci is dif- 
ferentiated from the true disease in which the diphtheria bacillus is rec- 
ognizable. In this, therefore, consists the enormous value of the recog- 
nition of the Loffler bacillus, and for this reason it is necessary that the 
physician should be so thoroughly trained in the determination of the bacil- 
lus that it is no longer necessary for him to require the proof from another 
source, even though it may be necessary to erect laboratories of investiga- 
tion to aid the busy practitioner. Only the physician must himself be mas- 
ter of the methods of investigation, for the examination is easy and may be 
readily carried out by any physician who has the slightest training. It is only 
necessary by means of forceps, previously rendered sterile, to take from the 
pharynx a shred of the pseudo-membrane; this should then be washed in 
boiled or sterile water, stroked upon Loffler's blood serum, which is readily pur- 
chasable, 2 or 3 tubes being used, well closed with sterile cotton, and kept in 
a place at the temperature of the body from five to six hours ; even after this 
time the characteristic growth of Loffler's bacillus may be macroscopically 
49 




Fig. 33. 



Pure Culture of Diphtheria 
Bacilli. 



754 



DIPHTHERIA AND DIPHTHERITIC CROUP 



determined, which naturally must be confirmed by the microscopic examina- 
tion of the dry stain preparation (Fig. 33) to determine the presence of the 

bacillus by its morphological proper- 
ties. This can be learned and per- 
formed by every practitioner; and if 
this appears too difficult for him he 
may at least take directly from the 
pharynx a small particle of the diph- 
theritic mass, wash it, smear it upon 
a cover-glass, allow it to dry, and 
stain it to determine at once the mi- 
croscopic picture, therefore, to dem- 
onstrate the presence of Loffler's ba- 
cillus without culture (Fig. 34). 
Naturally, this second method of ex- 
amination is not as certain as the 
first, the culture method; but for 
many, and even for most cases, it is 
sufficient. Therefore, there can be 
no error in the diagnosis, it will be 
impossible to mistake a scarlatinal 
angina or a follicular tonsillitis for 
diphtheria, but also, vice versa, the 
former diseases will not be assumed when actual diphtheria is present, in these 
cases, to the detriment of the patient, diphtheria being overlooked until too 
late to treat it with active remedies. 




Fig. 34. 



-A Preparation from 
l,ar Membrane. 



Tonsil- 



( Containing epithelial cells, leukocytes, mucus 
threads, staphylococci, streptococci, etc., 
and characteristic diphtheria bacilli.) 



THERAPY 

If there be a desire to become familiar with the entire deplorable helpless- 
ness of therapeutic procedures in the cure of a disease, then the history of 
diphtheria should be studied. Apart from tracheotomy, which was introduced 
into the therapy of diphtheritic croup by Bretonneau, Trousseau, and Guer- 
sant, and intubation first attempted by Bouchut and finally perfected by 
O'Dwyer to relieve laryngeal stenosis, the entire therapy of diphtheria, which 
for many hundred years, and even for thousands of years, has been in the 
hands of physicians, is a complete failure. I may say this, as since the begin- 
ning of my professional activity in a large country practice, as well as later in 
city practice, I have been in constant combat with this terrible disease, and in 
my hospital for many years, in spite of arrangements for the treatment of dis- 
ease which could not be surpassed, have had but the most deplorable and 
discouraging results. Tracheotomy alone excepted, physicians were almost 
helpless to ameliorate the course of this grave affection. With the best inten- 
tion to help them, what has not been tried and recommended among local, 
internal and external remedies in the long years since the more marked reap- 



THERAPY 755 

pearance of diphtheria epidemics in the second half of the nineteenth century, 
with what have not the poor children been tortured ! If it were not entirely 
superfluous, I could report all of these attempts, but it would require pages, 
and the sum of it all would be — that everything was futile ! Even after the 
discovery of Loffler's bacillus and of its toxins, when professional endeavors 
were actively directed toward neutralizing the bacillus in the human organism, 
I said — it is worth while to take a retrospective view of this kind — in a com- 
munication that appeared in the year 1892 regarding my therapeutic attempts: 
" Whether we look upon the diphtheria toxin as a toxalbumin, as an enzyme, 
or as another kind of chemical body which is produced in the organism itself, 
at the present time it displays an action which cannot be controlled because 
we possess no remedy to combat it." x4.nd then followed the enumeration of 
those methods and remedial agents which we have tried in vain. During this 
period of completely recognized helplessness, Behring made his discovery 
regarding the antitoxic action of serum in animals poisoned by diphtheria. 
After our former experiences, how skeptically the discovery of Behring was 
regarded may well be imagined. Step by step, however, our doubts disappeared 
because of the fortunate results which we, with Dr. Aronson, one of the former 
assistants of the hospital, attained with an excellent curative serum taken from 
horses. Then followed now, at first tentatively, but with increasing certainty, 
our communications regarding these fortunate results ; I allowed my assistant, 
at that time Dr. Katz, to report 128 cases at the meeting of the Berlin Medical 
Society on June 27, 1894; and then, in the year 1895, after the preceding 
lively discussion in reference to Hansemann's attacks upon serum therapy, I 
was able to publish 525 cases. 1 I should not have permitted myself to thus 
call attention to the development of my own observations, if the overwhelm- 
ing impression of the curative effect of serum therapy were not brought out 
in such an instructive manner; this forced the previously skeptic Yirchow to 
remark upon consideration of the figures obtained by us that by these " it was 
sufficiently proven that the curative serum develops a favorable action " — which 
I would not even admit if it depended upon the proportion of figures, and our 
own clinical detailed observations did not confirm it, because, particularly in 
the judgment of therapeutic results, there is nothing more deceptive than 
mere figures. I shall have to return to this at a later time. But what still 
further influenced me to refer to my own observations was the curious and 
rather conflicting fact that in his publications, apparently with definite pur- 
pose, Behring himself ignores the results which were gained at our laboratory, 
and by this curative agency, and scarcely appears to realize that, in spite of 
all the great honors which distinguished him, the introduction of his curative 
serum into practice would not have occurred for a long time if it had not 
received this support. 

Eegarding the curative serum itself, I may refer to Behring's and Ehr- 
lich's publication, the description of its method of production and the deter- 

i A. Baginsky, " Die Serumtherapie der Diphtheric," Aug. HirsclrwalcL Berlin, 1895. 



756 DIPHTHERIA AND DIPHTHERITIC CROUP 

in ination of its antitoxic value. We are concerned principally with its method 
of use. I have published everything that the practical physician should know- 
in my book, 1 have there also mentioned some of the inconveniences which now 
and then arise from its use, and shall here only refer briefly to the most impor- 
tant points. 

The quantitiy of antitoxin units to be employed in the individual case 
depends upon three conditions: 1, upon the duration of the disease; 2, upon 
the severity of the affection; 3, upon the age, that is, the size, of the sick 
child. Therefore, the largest dose will have to be used in the case of an 
older child which is well developed, of about thirteen years of age, and that 
has been suffering for about three days with general diphtheritic affection, 
showing phenomena of stenosis of the larynx. Such a case would require the 
employment of 3,000 antitoxin units. 2 On the other hand, in a young child, 
for examjole, about two years of age, upon the first or second clay of the 
disease, provided the general implication of the organism be not too marked, 
not over 1,000 antitoxin units would be necessary. In general it is well to 
use the full quantity in one injection, the action of the remedy should not be 
decreased by dividing the dose. Eegarding the necessity of using more anti- 
toxin units than was originally thought to be requisite, the observation that 
fever is still present upon the second day after the employment of the serum 
will enable us to decide, provided of course that there are no other causes 
for this fever than the diphtheritic infection, thus, for instance, an enlarge- 
ment of the glands, pneumonia, etc. The continuance of the symptoms of 
laryngo-stenosis or the especially slow loosening of the pseudo-membranes, 
which usually occurs in the first three or four days, may be the reason for 
giving another decided dose of 1,000 to 1,500 antitoxin units. Upon the 
whole, in the severest cases we have not exceeded 4,000 antitoxin units. [The 
most concentrated serum should be employed and care should be taken to 
procure that made in a well-conducted laboratory and not kept too long in 
stock. — Ed.] The curative serum must naturally be employed with all anti- 
septic precautions, but scarcely more care is necessary than is required in 
any other subcutaneous injection. We employ a glass syringe with a butt end 
of asbestos, and always select the external surface of the thigh as a point of 
injection. The injection should be given flat, subcutaneously, never too deep, 
about below the fascia of the muscle and into the muscular tissue. Too deep 
injections are very readily followed by abscesses. 

„ The action of the remedy is the more intense and more certain the earlier 
it is used after the onset of the disease; four to five days after the onset of 
the disease it loses its action in a great number of cases. 

This we were always able to observe in our cases, although an absolute 
certainty can never be acquired from figures and much depends upon the 
circumstances in the individual case. We may regard the fact as assured 

i A. Baginsky, " Die Serumtherapie der Diphtherie," Aug. Hirschwald, Berlin, 1895. 
2 \Ye have in America resorted to much larger doses. I never thought 20,000 units 
to be superior in its effects to 5,000. — Editor. 



THERAPY 757 

that, with the early application of the remedy, neither laryngo-stenotic phe- 
nomena nor septic infection of the organism occurs, but that the disease takes 
on a local non-toxic course soon after defervescence. I must not omit the 
warning that the physician should not be too cautious with the dose, further 
that he need not fear any secondary deleterious effects. All that has been 
designated by the opponents of serum therapy as evil secondary effects are not 
to be compared to the extraordinary results of cure, and what may eventually 
happen is at the most fever lasting two or three days, accompanied with an 
urticarial shin affection, occasionally arthritic pains; however, as I can assure 
any one from ,my very large experience, these are without importance and 
without subsequent damage. Truly, bad accidents, provided they cannot be re- 
ferred to very special conditions — I once saw a uremic attack in a child follow- 
ing an immunizing serum injection after measles — are exceedingly rare; and 
in the cases mentioned in literature in which death occurred this was due to 
entirely different causes than the use of serum. 

The favorable action of the remedy may be seen from the following signs: 
the decline of the temperature up to complete defervescence, and the euphoria 
going hand in hand with it; the arrest of the exudative and necrotic process 
at the local focus of the disease ; and, even if not in all, nevertheless, in numer- 
ous instances, the retardation of the laryngo-stenotic phenomena. This must 
not all be expected upon the day of the injection; moreover, not rarely an 
increase of the local process is still observed, but upon the second and cer- 
tainly upon the third day, if the amount of the injection has been sufficient 
an arrest of the process is noted and a demarcating redness surrounds the 
diphtheritic local focus and the disintegration and loosening of the membranes 
occurs. The peculiar change in color which the membranes undergo is re- 
markable; from a grayish-yellow to a grayish-green color, to a more light 
yellow color, which finally becomes a deep yellow. In many cases, and espe- 
cially in those in whom the serum treatment has been begun upon the second 
or third day, the danger is over with this antitoxic action of the serum and 
the patients enter upon an obviously increasing improvement, which becomes 
more noticeable day by day, leading without interruption to complete recovery. 

Let us now devote ourselves to the discussion of the local treatment which 
the diphtheritic areas require, besides the serum treatment. Fortunately, 
all the former mechanical and chemical measures that were employed to 
remove the diphtheritic membranes, the use of which tortured the children to 
a dreadful extent, have disappeared from our therapy. If we still employ 
these measures it is only to destroy the bacillus and to prevent the produc- 
tion of toxins, as the bacillus is not influenced in its property of life by the 
serum. For this purpose, gargles of potassium permanganate (2 to 1,000) 
or boric acid (3 per cent.) may be employed; or a soft cotton brush may be 
used to paint upon the parts a 1 to 2,000 solution of corrosive sublimate or 
a combination of ichthyol 5 per cent, with 1 to 2,000 corrosive sublimate, 
which is especially valuable as ichthyol kills the cocci that are present, whereas 
corrosive sublimate only influences the bacillus. Finally, powders that are 



758 DIPHTHERIA AND DIPHTHERITIC CItOUP 

easily insufflated may be utilized; sozoiodol in eombination with milk of sul- 
phur is best for this purpose. 

In how far we are able to retain the toxins which are formed by the 
Loftier bacillus in a nascent condition at the point of their production, even 
by submucous antitoxin injections, and to neutralize their first effects, as is 
proposed by Behring lately, I cannot decide, as our experiences have not been 
sufficient as yet. Eeasoning by analogy from experiments in test tubes and 
from trials with animals, and from results obtained, it is quite possible that 
unexpected cures may result from this application of the remedy and it is 
certainly worth a trial. 

Besides the measures already mentioned, we employ ice-bags and admin- 
ister ice internal l} r , which gives decided relief. 

It is hardly necessary to state that the patient must receive good nourish- 
ment and that it must be administered with care, in so far as this is possible 
during the febrile period. Small quantities of wine, perhaps also a cinchona 
decoction, may be administered to maintain strength, and with this the therapy 
of uncomplicated cases has been exhausted. 

The condition in diphtheritic croup and in* the sequelae previously men- 
tioned is different. Diphtheritic laryngeal stenosis requires, as I have already 
stated, the operation of intubation or tracheotomy. I mention intubation 
first, for, in fact, it is preferable to tracheotomy wherever it can be used. The 
instrumentarium is well known and I have described the manner in which 
the operation is performed in my book on Diphtheria very completely, besides 
the text is illustrated by exact photographs. The patients breathe very freely 
through the intubated tube. It is true, intubation is not a very easy operation 
and must be practised. In the hands of an unskilled operator, the intubator 
armed with the tube is a dangerous instrument which may cause death by 
producing injuries. If the tube has produced damage the children mostly 
die of secondary bronchopneumonia. This must be remembered and no one 
should attempt intubation until after thorough practice upon the cadaver. 
For this purpose I have had a model made which I keep in the post mortem 
room, upon which I allow my students to practise. The tube by its weight 
and by friction, especially if it remains in place for some time, brings about 
injuries which are designated tube ulcers, particularly the lower end of the 
tube causes this. 

With all this, the results of intubation in connection with serum therapy, 
are far more favorable than were formerly attained with tracheotomy. In 
this connection, I may refer not only to the publications of the skilled Amer- 
ican physicians, but also to those of Ranke, Bokai and others; we also, in 
general, have had very good results, so that among 109 cases reported at the 
Medical Congress at Moscow, of laryngeal stenosis treated by intubation, only 
9 ±= 8.73 per cent, died, and of all laryngeal stenosis 218, 40 = 15.5 per 
cent., a result which, compared with our former figures, is favorable beyond 
all expectation. These results, as I frankly admit, might even be better if 
.the dexterity of the operating assistants were perfect, but this can hardly be 



THERAPY 759 

attained on account of the constant change. From this illustration it can 
also be seen that mortality figures are dependent upon other causes than the 
disease itself and the remedies employed to combat it. 

Tracheotomy can also, as formerly, be used in laryngeal stenosis, but as 
it causes a wound which is obviated in the case of intubation, and this wound 
increases the difficulties and dangers, it has attained a secondary importance 
and is only utilized in cases that are not suitable for intubation, as in the case 
of a markedly narrow pharynx, etc. Naturally, the results of tracheotomy, 
which, as a rule, is only utilized as a secondary operation, are only secondary 
to those of intubation; thus, in li cases of primary tracheotomy, 10 = 71.4 
per cent., and in 22, after repeated intubation of secondary tracheotomies, 
15 = 68.2 per cent, of fatal cases. Eegarding the technique of tracheotomy 
and the after-treatment, surgical works should be consulted. Proper spray 
arrangements are also of value in the treatment of diphtheria. One of the 
most pleasing results of serum treatment is the spontaneous retardation of 
the stenotic laryngeal symptoms under the action of a properly used spray. 
Children with symptoms of stenosis of the larynx are allowed to inhale a 
strong spray of steam for hours, which contains at the most weak solutions 
of sodium chlorid or a 1 per cent, to 2 per cent, solution of boric acid. 

Eegarding the treatment of complications and sequels of diphtheria, we 
shall first speak of the cardiac affection. Unfortunately, little that is valuable 
can be said regarding the treatment of cardiac disturbances after they have 
once become conspicuous. The disturbance of the heart muscle that is due 
to the toxin of diphtheria can be but slightly influenced therapeutically. All 
of the heart tonics employed by us, small doses of digitalis, strophanthus, 
caffein, tincture of the chlorid of iron, etc., have proven unavailing. 1 No 
remedy has been able to arrest the advancing cardiac death; long rest in bed 
and good dietetic treatment have shown themselves to be the most valuable 
remedies in assisting children to withstand this threatening danger. The 
same is true of nephritis. Careful bland diet, alkaline mineral waters, here 
and there mild tannin and iron preparations, are almost the only remedies 
that' we employ. Rest and diet act best in this condition, and in summer 
change of air to a healthy country district is of value. The treatment of 
other complications, pneumonia, otitis, secondary lymph-gland abscesses, etc., 
is scarcely different in the case of diphtheria from that arising from other 
conditions. 

In conclusion, a few words regarding immunization of children threat- 
ened with contagion. In our trials with antitoxin treatment we began at the 
onset to give prophylactic antitoxin injections to the brothers and sisters of 
the patients who were brought to us affected by diphtheria, in order to protect 
them from infection. Fortunately, we were enabled to show in our divisions 

i Digitalis should be avoided. Add: fresh and cool air day and night, one or two 
daily washings with alcohol and water followed by friction, attention to the feet which 
must not be allowed to be cold, and the hypodermic use of salicylate or benzoate of 
sodio-caffein in collapse, as taught in another part of this book. — Editob, 



760 DIPHTHERIA AND DIPHTHERITIC CROUP 

of the hospital that if by any accident diphtheria were introduced we could 
always succeed in preventing its dissemination, as was also the case in threat- 
ened families. Since then, in a similar manner, immunization has been con- 
tinued in exposed places and our figures show hundreds protected. Whether, 
as Behring has lately wished and advised, general immunization of children 
against diphtheria, similar to vaccination, is to be introduced, or whether it 
be unnecessary to do this will depend upon the further course of diphtheria 
epidemics. It is certain that in threatened districts, especially in the country, 
the further spreading of the disease may be prevented by immunization. 
On the other hand, in the cases of children that can be well observed and are 
constantly under the control of physicians, we may content ourselves in em- 
ploying a sufficient dose of curative serum immediately upon the appearance 
of the diphtheritic attack. Up to the present our results with serum therapy 
teach us that early serum treatment is capable of preventing the dangers of 
the disease. Thus, it will depend perhaps upon the local and social conditions 
whether the physician is to employ one or the other method of prophylaxis. 
The dose for immunization purposes varies according to the age and size of 
the child, between 200 and 300 antitoxin units ; only rarely has this dose been 
increased. As a rule, this has proven sufficient. 

I might now close my discussion. I should not like to do this without 
clearing up a certain point which, unfortunately, serves to bring about a great 
deal of confusion regarding the value of serum therapy, and thereby incal- 
culable damage to our children, i. e., the application of the statistical method 
to determine the curative results attained. The value of statistics in ascer- 
taining the actual permanence of the processes and circumstances in things 
and in man is beyond all doubt and incontestable, and the less complicated 
the relations the more certain and likely will be the results which may be 
determined from such a compilation, grouping and addition. On the other 
hand, the scientific and conscientious statistician knows that on account of 
the complicating circumstances and relations attending figures, the difficulty 
of their proper estimation grows and the results may be far from the actual 
truth. What can be more complicated than the course of morbid processes 
in which certain positive factors as to age, weight, social position, the number 
of affections, etc., are taken into account, but also innumerable other condi- 
tions that cannot be mentioned, even unknown circumstances, such as the 
constitution of the patient, the nature and virulence of the pathogenic agent, 
the favorable influence of remedies and of physician, as well as faulty obser- 
vation and reports, and errors in treatment, may also affect the individual 
case. This renders professional statistics untrustworthy, and in so far as the 
most simple relations of figures are not taken into calculation, they are faulty, 
without value, and harmful. This accounts for the paucity of professional 
investigations and card index statistics, which scarcely include the simplest 
and most superficial relations of the investigations, not to mention the details 
of the individual morbid process. Only after a very large, almost enormous 
number of results, which include the omissions and errors of individual num- 



THERAPY 761 

bers, are observed, is a result attained which approximates the truth. This, 
above all, renders general statistical reports regarding therapeutic results 
valueless, and so much inferior to the experience of the faithful observer who 
notes the minutest details. Hence the useless and detrimental controversy 
with statistically produced small figures regarding the curative properties of 
serum therapy. Are the conditions of a single region similar to those of 
another, or is even one case exactty like another, and even in the same places, 
under the same physicians, persons, conditions, are the morbid processes 
exactly similar? Do we not even see in this hospital how the severity of the 
individual case varies, the children coming to us having entirely different con- 
stitutions, their disease and a thousand other conditions varying greatly? 
But just for this reason the observation of- an impartial, well-trained physi- 
cian who watches with open eyes is more valuable than all statistical reports. 
From this viewpoint, the judgment of serum therapy arising from careful 
clinical observations of the special case, with all the variations and surround- 
ing conditions, is the only proper one, and the one that comes nearest the 
truth. This is the reason why we do not turn to the right nor to the left, but 
singly and alone, holding to our own base of observation, we arrive at our 
conclusions regarding the curative value of serum therapy and shall even 
attain better results. 

Let me then say again in regard to the results reached by us, as far as 
human observation is able to judge, that in no disease of man have we attained 
such a certain remedial agent as is curative serum in the case of diphhtheria. 
This unalterable opinion is based on our own cases in which we have observed 
even the slightest variation. To us the individual figure is not merely a 
number but an actually observed case, and for this reason the sum of the num- 
bers does not confuse us. If in one month the mortality figure of 20 per 
cent, to 30 per cent, results, and in another only from 5 per cent, to 6 per 
cent., we can tell exactly why the figures could only be such, and why they 
could not be different. If in one month a greater number of severe septic 
cases, or children almost in extremis are brought to us with laryngeal stenosis, 
we know that the majority of these children will be lost and that our mor- 
tality reports will be more unfavorable, but this has absolutely nothing to do 
with the curative remed}^ at least not unless we ask that means be resorted to 
in human beings to bring the dead back to life; for, in fact, in those cases, 
for the most part, we are dealing with patients in whom death is absolutely 
certain. 

If now while taking into consideration all of these conditions, I say that 
our mortality figures in those cases which are at all susceptible of cure by the 
application of curative serum have improved in the proportion of three to one, 
if I say, further, that by judging the disease forms and patients under similar 
conditions, our mortality from diphtheria has decreased from about 45 to 15 
per hundred, this observation regarding the curative property of the serum 
appears to me to be more valuable than any number of statistical compilations 
can be. Do not allow yourselves to be confused by sophistries, do not allow 



762 DIPHTHERIA AND DIPHTHERITIC CROUP 

yourselves to be deterred by terrible pictures which have been described by 
inexperienced persons who have attempted to use serum treatment, do not 
allow an hour to go by if you are treating diphtheria patients without resorting 
to this life-saving remedy. 

Finally, to acquaint you with our rules, in a few words which should guide 
you in your therapeutics at the sick bed of diphtheritic children, I shall give 
the following: 

1. Use of the curative serum in sufficient dose as early as practicable, if 
possible immediately after the onset of the disease, in doubtful cases even 
before the diagnosis has been determined by a bacteriological examination. 

2. Local treatment of the diphtheritic membranes by mild applications 
or dusting by some of the remedies previously mentioned, without damaging 
the mucuous membrane and without unnecessarily torturing the child. 

3. Applications of ice-bags to the neck, and internal use of small pellets 
of ice. 

4. Saving and assisting cardiac power by good and proper nourishment 
and by absolute rest. 

5. Early relief of laryngeal stenosis by intubation or tracheotomy. 

6. Proper treatment lege artis of complications and sequelae. 



EPIDEMIC PAROTITIS, MUMPS 

By H. Falkenheim, Konigsberg 

Case History. — A boy aged seven, entiiely well up to a short time ago. Since three 
days ago not as active as previously. He began to show pallor, lassitude, he became 
irritable without definite symptoms of disease making their appearance. The mother 
then consulted a physician, as the child was very restless the night previously, com- 
plaining of earache and because a swelling had appeared upon the left half of the face 
accompanied by fever. 

The swelling is quite conspicuous. It occupies the region in front of the ear, reaches 
from the zygomatic arch downward to the angle of the jaw and reaches the posterior 
margin of the branch of the lower jaw to the groove between it and the mastoid process 
of the temporal bone, forcing the lower half of the ear, particularly the lobe of the ear, 
outward and somewhat anteriorly. The skin over the swelling appears pale, glistening 
and tense. The tumor itself has an elastic feel and is somewhat painful upon pressure. 
The child is hindered in eating, as pains arise in chewing. The tongue is coated, oral 
mucous membranes slightly reddened. The temperature is somewhat raised, 101.3° F. 
No other symptoms are discernible in the boy. 

The mother declares, upon being asked, that similar cases had not occurred in the 
child's brothers or sisters, but a playmate of the patient was affected in a similar 
manner fourteen days previously. 

The diagnosis is made by the mother. The boy has mumps, a condition which 
naturally will get well, but a school certificate is necessary, as the boy in his present 
condition is not permitted to go to school. 

In fact there is a swelling of the parotid gland. The gland is affected in its entirety. 
In a characteristic manner the swelling produces an alteration in position of the lobe 
of the ear. The limits of the enlarged gland may be readily determined by palpation. 
The swelling produces a doughy sensation in the surrounding areas. The nature of the 
glandular swelling, the absence of inflammatory changes upon the skin which covers 
it, the previous history, with the report of a similar affection in a playmate, the absence 
of other symptoms which might produce a swelling of the parotid, make it appear that 
the diagnosis of the mother is correct. The disease is well known among the laity 
on account of the peculiar distortion produced by the glandular swelling and the condi- 
tion becomes particularly noticeable in bilateral disease, the patient assuming a stupid, 
ludicrous appearance which has led to the disease receiving a number of popular names. 
It is well known that the disease in the main has a favorable prognosis and in a great 
majority of the cases does not require treatment. 

The patient whose history was just quoted showed a very mild affection, but on 
account of the fever rest in bed was ordered; to allay the tension of the gland, inunc- 
tions of warm oil covered with cotton, and a mild antiseptic mouth wash were ordered 
to keep the oral cavity clean; a bland fluid diet and a laxative were further adminis- 
tered. No complications having arisen and in particular, as is so frequent, the other 
side not being affected, the patient was completely well in a few days. 

HISTORY AND ETIOLOGY 

The knowledge of parotitis epidemica reaches far back. Hippocrates has 
given an accurate description of the disease. His experiences completely coin- 

763 



764 EPIDEMIC PAROTITIS, MUMPS 

cide with ours to-day. The benign character of the disease, the predisposition 
of youthful individuals, the extraordinary rarity of suppuration of the gland, 
the secondary inflammation of the testicle, were all known to him. The 
disease has not changed its character for centuries. It does not appear to 
be limited to particular climatic conditions. It has been noted in all zones 
and in all seasons. In the temperate zone it appears that the colder season 
seems to favor the disease. Thus in 117 epidemics collected by Hirsch, 51 
occurred in winter, and among 99 collected by Leichtenstern which were accu- 
rately studied, 42 began in the first quarter of the year, 17 in the second, 
9 in the third and 31 in the fourth. Prolonged cold and wet weather, 
sudden appearance of a cold season seem to favor the development of the 
affection. 

The contagiousness of mumps is beyond all doubt. As observations have 
taught us, transmission of the disease may not only occur at the acme of the 
infection but even before the glandular enlargement has appeared, and on the 
other hand, contagion may even occur in convalescence. As a rule, contagion 
occurs directly from person to person, but the disease may also apparently be 
conve} r ed by a third person, even by fomites. 

The extension of the disease occurs quite gradually. The contagium dis- 
tributes itself but slowly and only for short distances. Thus in boarding- 
schools, at first the inmates of the beds nearest the patient are attacked by 
the disease and then the disease is arrested, but this may occur, on the other 
hand, as the result of simple isolation. Often the disease only occurs in a 
single building, a school, an orphan asylum, a prison, a fortress, and does 
not occur be} r ond the walls, disappearing after all predisposed inmates have 
had the affection without attacking those living beyond these confines. At 
other times a house epidemic becomes a city epidemic or even affects an entire 
province. The disease may even obtain pandemic distribution. As in the 
case of scarlatina, measles, sporadic cases also occur in parotitis epidemica. 
In some regions mumps appears every year, in other districts only every five or 
every ten years, again sparing other regions for a much longer period. There 
are no distinct relations to other infectious diseases, such as to scarlatina, 
measles, etc. The epidemics may occur in different groups and occur side by 
side. That children attacked by mumps are not affected by scarlatina, as was 
observed by Schonlein and Frank, has not been confirmed by later observers. 
The simultaneous occurrence of mumps with measles, with varicella, with 
influenza, was noted by Hochsinger a few years ago (Centralbl. f. Ki?iderhl\, 
1898, Kr. 12). 

The infectiousness varies in different epidemics. While in one the majority 
of children are attacked, especially if they come in closer contact with each 
other, thus, for example, in an orphan asylum in Moscow among 300 children, 
167 were attacked ; in an epidemic observed by Liihe in a cadet school in Ploen, 
among 131, 118 were attacked — in other epidemics, in families, in children's 
hospitals, without special isolation, but few cases have occurred, although the 
inmates had not previously suffered from the disease. The severity of the 



HISTORY AND ETIOLOGY 765 

affection in different epidemics is also subject to certain variations. In some, 
though comparatively rare, the cases lose their harmless, ludicrous character, a 
severe disease appearing with threatening complications. 

As a rule, the disease attacks an individual but once, second attacks being 
exceptional. More frequent attacks than this are extraordinarily rare, particu- 
larly in children. Comby saw a girl aged twelve years have an attack of 
mumps three years after a first attack. Both attacks were unmistakable. 
Soltmann has seen several such cases and Hochsinger only recently reported 
cases of this kind. 

Children between the ages of five and fifteen are especially liable. Children 
under two and the aged are rarely attacked. In adolescence the predisposition 
is still quite marked. There are numerous reports, especially from France, 
regarding epidemics occurring in barracks. After the fortieth year of life the 
disease is very rare. The greater predisposition of youthful age, as Leichten- 
stern remarks, may also be distinctly seen from the fact that in a house epi- 
demic first the younger children, then the older ones and finally, if at all, 
adults are attacked. In 73 cases Eilliet and Lombard noted the affection in 
37 children between five and fifteen years, in 7 between three and four years 
and none at an earlier age. Soltmann's youngest patient was a year and 
three quarters old. Steiner's, one and a quarter year old. My youngest 
patient was only seven months old. It is entirely exceptional that children 
as young as this are attacked. As a rule nurslings and the newborn are im- 
mune to the disease and repeatedly a wet nurse who has been attacked by 
mumps has been allowed to go on nursing the child, without the child hav- 
ing been attacked by the disease. Gautier observed in an infant, whose mother 
was attacked by mumps, a swelling of the submaxillary gland. White saw 
a child six days old and its mother a day later, attacked by parotitis, the 
mother having a severe affection, while other cases occurred in the neighbor- 
hood simultaneously. Homans found, in the child of a woman whose labor 
came on in the eighth month as the result of parotitis, a swelling of the left 
parotid gland on the day after birth. The swelling increased upon the two 
next days and was distinctly painful. These observations permit us to reflect 
upon the possibility of intrauterine transmission. 

Sex does not show a difference in regard to the disease. The apparent 
predominance of the male sex is due to the greater frequency with which this 
sex is exposed to contagion, as in schools, cadet schools, barracks, etc. (Comby). 

The infection in all probability occurs from the oral cavity and the germs 
find their way thence to the mouth of the glands. On account of the lack of 
development of these glands and on account of the narrowness of Steno's duct 
in nurslings, Soltmann sees the condition which confers immunity at this age 
of life. Many attempts have been made to discover the nature of the patho- 
genic agent. Up to the present no uniform result has been obtained. The 
investigations of Laveran and Catrin deserve attention ; these authors detected 
in the blood, in the- parotid and in the testicle, in the fluid of the edema, 
diplococci. The investigations of Michaelis and Bein, who in two cases found 



766 EPIDEMIC PAROTITIS, MUMPS 

diplococci in Steno's duct and in the pus of an ahscess of the parotid are also 
noteworthy. These investigations, however, require further proof. 

PATHOLOGY 

What pathological changes occur in the parotid in mumps have not been 
determined with certainty. Pure cases are not fatal. As only changes can 
occur which are susceptible of complete cure it is assumed by analogy that 
a sero-fibrinous transudation of the periglandular and inter-acinus cellular 
tissue occurs, whereas the tissue of the gland itself in the main presents a nor- 
mal condition. Gerhardt saw the diseased gland furnish a secretion which 
corresponded to the normal. Lombard noted the same condition. Jacob 
found, in a soldier who was attacked by mumps and who perished on account 
of edema of the glottis, that the salivary gland was not enlarged, but the cell 
stratum was filled with a greenish gelatinous fluid, the entire tissue being of a 
lardaceous consistence. Ranvier proved the absence of inflammatory changes 
by microscopic investigation. The epithelium of the glandular canal was 
unchanged, cell proliferation was not present. There was edema of the glottis, 
edema of the inter-acinous tissue. That, however, in severe cases the gland 
cells may also show anatomical changes is quite possible. Suppuration occurs 
with exceeding rarity in parotitis; and then only a part of the gland is des- 
troyed. Although in a portion of the cases the assumption of Leichtenstern 
may be true, that areas of the gland, as the result of a high grade of swelling, 
are disturbed in their nutrition and thus destroyed and desquamated by demar- 
cation, in other cases there is only a secondary infection with pyogenic agents 
from the mouth. 

After infection has taken place a period of incubation arises, the duration 
of which has been variously estimated by different authors. In general we 
may count eighteen days, although somewhat longer periods of incubation 
(twenty to twenty- two days) are also quite frequent. Demme saw several cases 
in which the period of incubation lasted but three days. Dukes noted cases in 
which this was twenty-four days. 

SYMPTOMS 

Prodromal symptoms vary in individual epidemics. They may be entirely 
absent in a number of cases or so slight that they are overlooked and only the 
swelling of the gland denotes the presence of a disease. In other cases the 
children become irritable, unwilling to play and are languid. They lose their 
appetite, their sleep is disturbed, fever occurs, which exceptionally may reach 
even 104° F. Older children even complain of headache, of fleeting pains in 
the parotid region, the sensation of a certain tension in the neighborhood of 
the angle of the jaw upon opening the mouth. The mucous membrane of the 
mouth shows catarrhal inflammation. Younger children grasp their head and 
the ear with their hands. The gastro-intestinal symptoms are quite marked 



SYMPTOMS 767 

in some epidemics. Soltmann in his youngest patient saw the attack begin 
with severe fever and an eclamptic attack. Rarely do these prodromes last 
longer than from one to three days; then with increasing sensitiveness in 
the parotid, with an increase in tension, with a growing limitation of the move- 
ment of the jaw, the swelling in the parotid rapidly appears, most often upon 
the left side. The gland rises in the groove between the lower jaw and the 
mastoid process, shows itself as a broad swelling, transversely over the branch 
of the inferior maxillary and distributes itself in the region in front of the 
ear. The lower portion of the ear is raised, forced somewhat anteriorly and 
the readily movable lobe of the ear is almost placed in a horizontal posi- 
tion. In intense cases the swelling advances beyond the immediate surround- 
ings of the parotid. The subcutaneous cellular tissue becomes edematous, 
infiltrated and has a doughy feeling. The limits of the parotid become indis- 
tinct, the swelling in some cases may reach to the orbit, the palpebral space 
becomes narrowed, the conjunctiva injected. The swelling may distribute 
itself over the entire cheek up to the angle of the jaw and the submaxillary 
and sublingual glands may take part in the morbid process, the swelling 
reaching to the clavicle. The normal division of the neck is then lost, the 
region of the neck is broadened, and if the disease occurs bilaterally the neck 
may be broader than the face. Occasionally the parotid as a whole is not 
attacked at once, but in individual exacerbations. The skin over the swollen 
area is tense, pale, glistening. The glands are sensitive to pressure. It is 
noteworthy that in some cases the submaxillary gland, more rarely the sub- 
lingual gland, are alone attacked (Penzoldt), whereas the parotid may be 
spared or only be affected later on (v. Strumpell). These cases gain a cer- 
tain diagnostic interest, particularly when judging of secondary clinical symp- 
toms after the swelling has disappeared. Under some circumstances in a family 
one child may be seen with a swelling of the parotid, another child with a 
swelling of the submaxillary gland. 

By means of the enlargement of that portion of the parotid which rests 
upon the biventer in the retro-maxillary groove, such pressure may be exerted 
that the resistance of the deep fascia of the neck may be overcome. The lat- 
eral wall of the pharynx with the tonsil will then be forced anteriorly and the 
isthmus of the fauces narrowed. Pressure may be exerted upon the larynx 
and upon the upper portion of the trachea. Partly as the result of pressure 
upon the vessels, edematous swelling of the mucous membranes of the pharynx 
and of the larynx may occur, as also the symptoms of severe laryngeal stenosis. 
On account of disturbance in respiration in connection with venous hyperemia 
as the result of pressure upon the veins of the neck, in bilateral, high-graded 
parotitis, even with moderate fever, cerebral disturbances may occur. The 
movements of mastication and deglutition as well as speech are made difficult 
and painful by the swelling. The muscles suffer a functional damage, the 
enlarged parotid lying as a mass below the branch of the lower jaw, hinders 
the backward motion of the food in chewing ; the mouth can scarcely be opened. 
Under some circumstances the enlargement may reach so high a grade that 



768 EPIDEMIC PAROTITIS, MUMPS 

not only solid food but even fluid is refused and the consequences of this 
become apparent. The proper care of the mouth, on account of insufficient 
opening of the mouth, cannot be correctly carried out, hence a decidedly fetid 
breath occurs. Catarrhal stomatitis may appear. Occasionally the surround- 
ings of the mouth of Steno's duct are reddened and swollen and the duct itself 
may be felt as a stiff band. 

The salivary secretion in a number of cases is not altered; in others it is 
increased or diminished. 

Displacement of the posterior lower auditory meatus, swelling of the exter- 
nal auditory meatus, and on the other hand of the Eustachian tube, lead to 
disturbance of hearing and produce pain which influences the sleep of the little 
patient. 

Often in particularly well marked cases the movements of the head become 
painful; the head is held rigid and, as a rule, slightly inclined toward the 
diseased side, besides it is somewhat retracted so as to lessen the tension of the 
muscles of the head; in a bilateral disease the head is held straight in a 
medium position, somewhat posteriorly, or even bent somewhat anteriorly. 

Occasionally, as the nerve is implicated, facial paralysis is produced. This 
occurred in the nursling aged seven months mentioned above. DeR were dis- 
tinct. In six weeks recovery occurred. 

The frequency with which the second parotid is affected in the course of 
the disease varies in different epidemics. The most usual condition, in general, 
is that a few days after the swelling of one parotid the other is also affected, 
but this does not occur to the same extent as in the first gland ; but epidemics 
also occur in which it is quite exceptional that the disease is not limited to one 
side. 

Although completely afebrile cases exist, still, as a rule, in the course of 
parotitis there is fever. Even in the prodromal stage in a great majority of 
cases this occurs, although the rise in temperature is often slight and only 
noted in the afternoon, so that in case the other symptoms are not well marked 
it may readily be overlooked. With the appearance of the swelling of the 
parotid the fever rises, as a rule, not over 102.2° F., but there are also cases 
with a decidedly higher febrile course, 104° F., 106.7° F., even lasting for 
several days and accompanied with prostration, apathy, somnolence and even 
convulsions, in some epidemics. After a few days, when the parotitis has 
reached its acme, the temperature falls to normal, occasionally quite sud- 
denly, accompanied with sweating, even before the local process has run its 
course. The fall in temperature is interrupted and at first a new rise oc- 
curs, but not to the former height, if the disease attacks the other side. If 
relapses occur these renewed rises in temperature are noticeable, as well as with 
the appearance of complications a decided rise of temperature accompanied 
with chilly sensations. Thus the fever period, which usually ends in about 
seven days, may last for fourteen days and even longer. 

The pulse frequency corresponds to the temperature in so far as it is not 
influenced by pain and restlessness. 



COURSE AND TERMINATION 769 

In severe cases at the height of the disease enlargement of the spleen may 
be noted (Ewart) also swelling of the cervical lymphatics. 

The duration of the disease in uncomplicated cases is in the main de- 
pendent upon the intensity of the glandular swelling. In medium severe cases 
this increases for three or four days and then after edema in the surround- 
ing area becomes less noticeable and the glands are softer, normal conditions 
are gradually assumed. If the tension of the skin is high graded, bran- 
like desquamation occurs. In the ordinary cases the process is finished in 
from eight to fourteen days. In the severer cases this lasts longer and in 
the abortive cases the process is finished in a few days. In some cases the 
course is a very protracted and stubborn one. It may take from five to six 
days until the swelling reaches its acme and if the second gland becomes at- 
tacked this period may be even longer, whereas it usually occurs in from one 
to two days, occasionally after three days. 

COURSE AND TERMINATION 

The course and termination of the disease, as a rule, are favorable even 
in those eases in which complications occur. The parotid returns to the 
normal although it occasionally happens that for a long time, for the most part 
in connection with surrounding lymph glands, it remains infiltrated and only 
gradually returns to normal. Occasionally functional disturbances lasting 
for some time are observed. Thus Eichhorst saw in a boy aged nine, for 
three months a decided Irypersecretion (cured by atropin). Similar cases 
were seen by Simon and Prautois ; Burton on the other hand saw a diminution 
in secretion, which was cured by galvanization. Suppurative processes which 
then only attack a part of the gland are in the main extraordinarily rare. In 
individual, particularly malignant epidemics, this unusual complication may 
become frequent, thus in the epidemic at St. Cyr, and in an epidemic observed 
in Berlin in the spring of 1825 by Huf eland. 

The most peculiar complication of parotitis is disease of the testicle, which 
was even known to Hippocrates. This is frequent in men, exceptional in the 
aged, who in fact rarely suffer from parotitis, and occasionally noted in boys 
who are near puberty, in the ages of twelve and fourteen years. In earlier life 
it is extraordinarily rare, a fact to which Laghi called attention. Fabre's 
patient was nine years, uNTaumann's eight years. De Cerenville saw orchitis 
in a patient aged four and Steiner even in a nursling, the only case of this 
kind. 

It is interesting that occasionally orchitis may precede parotitis and that 
at times of mumps, orchitis parotidea may occur without parotitis being ob- 
served; a complete analogy to the condition occasionally shown in disease of 
the submaxillary gland in parotitis. The case of Beclere is characteristic. A 
boy aged fifteen, in whose school mumps was epidemic, was attacked by orchi- 
tis without parotitis, two of his sisters being attacked by parotitis. 

The frequency of orchitis varies in individual epidemics of mumps and 
50 



770 EPIDEMIC PAROTITIS, MUMPS 

the appearance of orchitis is quite independent of the severity of mumps. 
Rizet even observed an epidemic in which, particularly in the milder cases, 
orchitis occurred. Patients with gonorrhea, as the observations of military 
physicians have shown, are by no means particularly predisposed to orchitis. 

If orchitis occurs, the testicle usually swells some time between the sixth 
and ninth days of the disease, whereas the parotitis is already upon the decline, 
the testicle swelling two to three times its normal size. Usually it is the right 
testicle. In unilateral parotitis, according to Monti, the left testicle is affected. 
Simultaneously the temperature rises, often with an initial chill. In the 
testicle itself, there is a sensation of dull pressure, of tension, also severe pain. 
Neighboring organs usually remain completely free but they may also be impli- 
cated by thickening and swelling. Acute hydrocele may occur, and the scro- 
tum may become edematous and painful. Bilateral disease of the testicle is 
decidedly rarer than bilateral parotitis. If the second testicle becomes affected 
this occurs after two to four days ; the swelling of the testicle in general lasting 
from three to six days. This also, as the enlargement of the parotid, as a rule, 
returns to normal without further consequences; but it must be noted that this 
condition is not so benign, for particularly according to the reports of French 
military jmysicians, in a comparatively large number of cases, atrophy of the 
testicle has been observed, which for the most part was only partial and not 
followed by impotence. 

Occasionally prostatitis occurs; occasionally also urethritis and cystitis. 
Rilliet and Sanne noted in a school epidemic among 10 cases of orchitis, 5 with 
a yellowish tenacious secretion from the urethra. 

In what the connection consists between the parotid gland and testicle, 
which forms the basis for the peculiar implication of the testicle in parotitis, 
and in what manner orchitis occurs has not yet been cleared up. Orchitis has 
been noted with particular frequency by military physicians, especially in 
France, in epidemics occurring in barracks, and this gives rise to the possi- 
bility that the germs have been directly transmitted to the urethra, rinding 
their way upward into the testicle — an assumption which finds a certain sup- 
port in the fact that in a number of cases urethritis is noted, but by no means 
in all. 

In the female the genital tract is also implicated, but by no means so 
frequently. Besides vulval vaginitis, Bartholinitis, swelling of the large labia, 
urethritis, menstrual disturbances, there occurs also, analogous to orchitis, 
disease of the ovaries. Yoigt saw in a girl aged eleven, in the course of 
mumps, the right ovary swell to the size of a chestnut, being painful upon 
pressure. The mammary gland may also swell and be painful. Travel ob- 
served this disease in a patient aged fifteen, Eizet in a girl aged five. Occasion- 
ally in the male, mastitis parotidea occurs. 

Guelliot noticed a transitory swelling of the thyreoid gland. Occasionally, 
however, rarely, the implication of the tear gland on the one side as well as 
bilaterally has been noted with swelling of the upper eyelid, so that the tear 
gland could be felt resembling a hard kernel. Jacob claims to have noted 



PROGNOSIS 771 

a pancreatitis occurring acutely and subsiding in a few days, producing a sau- 
sage-like tumor, sensitive to pressure below the liver, accompanied by pain in 
the epigastrium, vomiting, fever (104° F.) in the course of mumps. 

Albuminuria has been frequently noted and also cases of true acute infec- 
tious nephritis, sometimes of a hemorrhagic character (Pratolongo, Isham, 
Henoch, Croner and others). As a rule recovery occurred. 

Among other complications which have occasionally been noted there are 
to be mentioned, endocarditis and pericarditis ( Jaccaud, Grancher and others) 
terminating in recovery, otitis, osteomyelitis, articular and tendon affections 
such as occur in the course of scarlatina and gonorrhea, but much more rarely 
and milder. Occasionally with erythema and various cutaneous affections 
(erythema nodosum, papulatum, urticaria, petechia). Severe disturbances on 
the part of the respiratory tract apart from the previously mentioned case of 
edema of the larynx, from which, per example, Pailhas also lost a boy aged 
eleven, have rarely been observed ; on the part of the digestive apparatus, stub- 
born vomiting, severe colic, marked diarrhea, finally all terminating favorably. 

Milder affections of the same category belong to the picture of mumps, 
especially if fever is present. On the part of the nervous system there are par- 
ticularly reports from French observers that occasionally in the course of 
parotitis and in connection with the same mental disturbances, delirium, con- 
vulsions and meningitis occur. These complications occurred in the main in 
severe, markedly febrile, cases in neuropathic children (Comby), associated 
with orchitis. Lately Heubner in his text-book has mentioned an interesting 
case of this kind in which in a strong, intelligent boy aged thirteen a complete 
psychosis developed with absolute disappearance of memory for former events 
and f orgetfulness of surroundings, which after a period lasting several weeks of 
sleep and dream life, gradually terminated in recovery. Multiple neuritis 
(Joffroy) has been noted as after other infectious diseases, and in rare cases 
besides conjunctivitis severe affections of the eye, keratitis (Zossenstein), iritis 
(Collomb), retinitis (Hatry), neuritis optica (Tallon) with amaurosis. 

It is noteworthy that apart from otitis media, on account of the immediate 
neighborhood of the diseased parotid gland, disturbances of the ear occur 
partly without a primary otitis media; severe labyrinthine disease without 
noteworthy prodromes, with unilateral or bilateral deafness ; attacks of vertigo 
and headache may appear which give but small hope for the return of hearing 
(Toynbee, Pierce, Alt and others). Although these occurrences are rarer in 
children than in adults, still several cases have been reported in which chil- 
dren under thirteen have become deaf in the course of mumps. 

All of these various complications, mentioned on account of completeness, 
do not play an important role in parotitis. Orchitis is • the complication 
/car i^o^rjv. 

PROGNOSIS 

The prognosis of the disease upon the whole and in the main may be desig- 
nated as good, although occasionally epidemics occur in which severe cases 



772 EPIDEMIC PAROTITIS, MUMPS 

accumulate. Even these in general terminate favorably. Fatal cases are 
extraordinarily rare. Among 58,331 cases of parotitis which were reported in 
Denmark from 1870 to 1894 Ringberg (Jahrb. f. Kinderhk., Bd. xlvii, page 
313) only found 7 which terminated fatally, among these 3 children (2 in the 
first year of life). Nevertheless, as Leichtenstern quite properly emphasizes, 
mumps may become serious in that in scrofulous children it occasionally forms 
the starting point of serious diseases, particularly glandular suppuration. 

DIAGNOSIS 

The diagnosis, as the result of the characteristic symptoms which paro- 
titis furnishes, can scarcely be missed. When the lymph-glands in front of 
the ear, at the angle of the jaw, begin to enlarge rapidly, the surrounding con- 
nective tissue is involved in the inflammatory process and a doughy swelling 
arises; at the onset, before the skin reddens, before abscess formation becomes 
plain, the diagnosis of parotitis may be incorrectly made. This occurs, but 
may be avoided if it be remembered that in parotitis the groove between the 
mastoid process and the lower jaw becomes filled, a broad tumor forming in 
this region, that the parotid becomes sensitive to pressure, not, however, so 
painful as a beginning abscess. A confusion with secondary, so-called, meta- 
static parotitis is scarcely possible. This is observed in purulent inflamma- 
tions of the mouth and pharynx, in diphtheria, particularly in severe typhoid, 
in fact in diseases, especially in acute ones, which go hand in hand with 
severe prostration, such as acute exanthemata, in puerperal sepsis of the 
mother and newborn, due for the most part to the entrance of pyogenic organ- 
isms from the contaminated mouth through Steno's duct into the gland, partly 
perhaps also from blood infection. Although here as in parotitis, the paro- 
tid gland itself enlarges and in this way the local symptoms show great simi- 
larity to mumps, especially as in metastitic parotitis, on account of apathy 
and somnolence, the pain may not be so marked, nevertheless the presence of 
the primary affection, the fact that the parotitis occurs upon one side, the 
slower development, the greater extent of the tumor and the tendency to 
abscess formation, assist the diagnosis into the proper direction. Difficulties in 
the clinical picture of mumps only occur when the submaxillary gland or the 
sublingual gland, without implication of the parotids, swells, or this condition 
precedes enlargement of the parotid, or if after the glandular swelling has 
returned to normal, complications, particularly orchitis, must be of value as 
diagnostic aids. 

THERAPY 

The treatment in general is very simple. In a majority of cases covering 
the gland, to keep out deleterious external substances, application of warm 
oil, covering with cotton, keeping the mouth clean by rinsing with antiseptic 
fluids, bland, mostly fluid diet, regulating the bowels, and if fever is present, 
rest in bed. In a great number of cases the physician is not consulted at all 



THERAPY 773 

as the affection is known to be benign. Special attention is to be given to 
the care of the mouth. If the return to normal of the enlarged gland should 
be protracted, iodin preparations may be used, per example, inunction with 
iodin vasogen, painting with iodoform collodion (1-15), etc. If, exception- 
ally, suppuration occurs the gland is to be incised, great care being taken not 
to cut the facial nerve branches. In orchitis, rest in bed is necessary, eleva- 
tion of the diseased organ, the application of cold or if this is not well borne, 
of moist warmth. All severer symptoms and complications are to be treated 
according to general principles. The fact that these conditions arise in 
mumps does not require a change in their management. 

After all symptoms have disappeared, a few days after the parotid swell- 
ing has returned to normal, the children ought to be bathed. They may then 
leave the house and come in contact with other children. Although it is 
correct, that most frequently isolation is practised too late, because profes- 
sional opinion is not consulted on account of the long period of incubation 
or the slightness of the affection, nevertheless the patients are to be isolated. 
In regard to the mildness of mumps, Henoch believes isolation to be unneces- 
sary and Laveran is of the opinion that children should be exposed to the 
infection to protect them in later life from the complication with orchitis. 
Although mumps in childhood, in by far the greater number of cases, does 
not give occasion for the slightest anxiety, still the possibility must be con- 
sidered that parotitis in youthful individuals, although very rarely, may take 
a severe course, may be complicated by nephritis, otitis media, etc., and may 
be the starting point of the appearance of scrofulous phenomena. To this 
may be added that on account of the limitation of the predisposition to the 
disease the possibility exists that persons may remain spared from the affec- 
tion. By immediate isolation of sick children in large institutions, schools, 
etc., a further distribution of the disease may be prevented. As we are deal- 
ing with an infectious disease in mumps, disinfection of all materials that 
have been in use and thorough cleansing of the sick room is advisable. It is 
well in regard to the mildness of the disease only to undertake the most neces- 
sary measures ; all the more, as those about the patient, are not even inclined 
to do this, if inconvenience or cost be associated with these measures. 

Literature 

Leichtenstern, " Parotitis epidemica " in "Gerhardt's Handb. d. Kinderkrankh.," 1877, ii, 

p. 649. 
Vogel, " Krankheiten der Lippen und Mundhohle " in " v. Ziemssen's Handb. d. spec. 

Path. u. Therap.," 1878, vii, 1, p. 91. 
Longuet, " L'union medicale," 1885. 
Mettenheimer, " Jahrb. f. Kinderhk.." 1891, p. 383. 
Marfan, " Rev. mens, des maladies de l'enfance," 1894, p. 420. 
Saltmann, " Parotitis epidemica " in " Eulenburg's Real-Encykl. d. ges. Heilk." Dritte 

Aufl., 1898, Bd. xviii, p. 323. 
Comby, " Traite des maladies de l'enfance," second edition, 1904. 



PERTUSSIS, WHOOPING-COUGH, TUSSIS- 
CONVULSIVA 

By A. Baginsky, Berlin 

In" observing a young child that is . coughing, if the cough be accompanied 
by a peculiar loud, sighing inspiration, several points are to be noted by a 
careful diagnostician. If the cough is severe, forcible, paroxysm upon parox- 
ysm succeeding one another and finally accompanied by a spasmodic laryngo- 
stenotic apnea, so that the face assumes a dusky hue and finally becomes 
cyanotic, the entire attack showing a threatening character, it is quite evident 
that such a child is suffering from pertussis, an infectious disease of childhood. 

Two points should be noted at once, that a cough of this character pre- 
sents an affection sui generis, and secondly, that such a child should be iso- 
lated, as it is suffering from a transmissible disease. This affection of child- 
hood, which apparently presents a severe character, is the purpose of the 
present monograph. 

GENERAL CLINICAL PICTURE 

Case History. — A boy, aged four, in whom at first glance no pathologic condition 
can be noted. The mind is clear, cheeks are red, perhaps somewhat rounder and fuller 
than is usually noted in children of this age, the child presenting, in general, the ap- 
pearance of robust health. Pulse and temperature show nothing abnormal, nor does the 
character of the child's respiration; upon undressing it, however, it appears that the 
child, apparently in the best of health, does not show a condition of nutrition upon the 
rest of the body in harmony with the full face, above all, on account of the flaccid condi- 
tion of its adipose tissue. The child, upon the whole, is not as well nourished as might 
appear at first glance, the fatty tissue is soft, flabby, the skin is quite dry, almost 
wrinkled upon the arms, abdomen and legs, and we cannot escape the impression that 
the face shows a someAvhat bloated character, which renders it very probable that the 
condition of nutrition of the body is not as good as it formerly was. 

In searching for the possible reason of this retardation in nutrition, we find that 
neither the temperature curve nor the condition of the urine nor the feces of the child 
furnishes a clue; only one thing may give us a point of support for this explanation 
and this is the report that the child suffers from severe attacks of cough, which are 
frequently accompanied by vomiting, that these attacks of cough and vomiting occur 
from four to ten times a day and even more frequently. If the child takes nourishment 
after an attack of coughing and vomiting of this sort, it may readily occur that the 
interval between the attacks of cough are not sufficient for complete gastric digestion, 
that is, for a definite removal of the food from the stomach to the intestinal canal. The 
parents report that the child has lost weight. 

Physical examination shows normal conditions throughout. Everywhere, over the 
thorax, vesicular respiration, nowhere accompanied by catarrhal rales, nowhere abnormal 

774 



PATHOGENESIS AND ETIOLOGY 775 

dulness; on the contrary, if anything were noteworthy, the decrease in cardiac dulness, 
which is apparently due to the fact that the pulmonary tissue covers the heart from 
right to left, showing a lessened volumen auctum pulmonum is noticeable. However, 
the heart sounds are normal and pure; neither in the organs of the abdomen can any- 
thing abnormal be determined either by palpation or percussion. 

In examining the pharynx and the mucous membranes of the child by means of a 
tongue depressor, placed over the dorsum of the tongue, the child has an attack of 
coughing and suffocation. 

This attack has some special characteristics. It is noted that the cough is of quite 
unexpected severity. While the hollow cough becomes more superficial and shorter, 
paroxysm following paroxysm, the face of the child becomes dark red, the tongue is 
protruded, the eyes are prominent appearing injected and moist, lacrymation occurring; 
inspiration during the individual paroxysm of cough is insufficient, the child can scarcely 
breathe, and only from time to time, between the paroxysms, does a deep, hasty, sighing 
sound occur, a long continued inspiration; masses of glassy, moist, foaming mucus are 
brought up; this continues almost up to the point of complete exhaustion. Finally 
the force of the cough appears broken, the paroxysms become briefer, rarer, looser, the 
child resumes its normal color and appearance. But not yet completely; apparently the 
child is disturbed by a new sensation; it appears to suppress a tickling in the throat, 
it endeavors to swallow to master this ; the facial expression becomes somewhat anxious. 
In fact the cough breaks out anew, this time even more severely than in the first attack. 
The child can scarcely breathe, so rapidly do the paroxysms of cough follow one another, 
so short are the pauses which permit inspiration, and now the cough is accompanied by 
retching, followed by vomiting, which evacuates the contents of the stomach accompanied 
by masses of glassy mucus, not without continued troublesome retching and occasional 
attacks of cough. Finally the child is free from cough but in a dreadful condition! 
Covered with perspiration, exhausted, pale and tired. The pulse has become soft, fre- 
quent, over 120 beats per minute. It is plain that this represents a characteristic of the 
disease, and it is easy to understand that if attacks of this kind occurring from five to 
six times during the day and perhaps more frequently during the night — for in fact 
the nocturnal attacks are more frequent and even more severe than those which occur 
during the day — are repeated, the nutrition of the child may very readily suffer. 
Thus we understand the contrast between the apparent fullness of the face, which in 
fact is puffy — it would be too much to say edematous, — and the condition of nutrition 
of the rest of the body. 

PATHOGENESIS AND ETIOLOGY 

Whooping-cough, pertussis or tussis-convulsiva, is a disagreeable disease 
and one which may extend for weeks and months, finally enfeebling the 
strongest children, becoming dangerous to younger ones but may even be 
serious in older children to such an extent that many years may pass before 
they regain their normal constitutional condition, even if no complicating 
affections threaten the life in older patients, which may readily be the 
case. 

The disease unquestionably belongs among the infectious diseases; it is 
not very readily transmitted, but this certainly occurs by contact between 
children; however, this may take place, as I have observed with certainty, by 
means of third persons who come in contact with sick children, conveying 
it to those that were previously healthy. The contagium adheres to rooms, 
to fomites; it is actually one of those diseases which are readily distributed 
through a school. In truth the disease spares no age ; it occurs in the young- 
est nursling as well as in adults, although children during the ages from one 



776 PERTUSSIS, WHOOPING-COUGH, TUSSIS-CONVULSIVA 

to four are most susceptible. I am able to give the following figures from my 
own observation: Among 2,650 cases admitted to the hospital in ten years 
the following cases were observed : 

830, in the first year of life. 

1,308, one to four years old. 

502, four to ten years old. 

11, ten to fourteen years old. 

Although the number up to four years, in general, is somewhat greater 
than that between four and fourteen, the frequency of the disease during 
the first four years of life is comparatively much greater, so that there is 
certainly a predisposition for this age. It will be noted that nurslings are 
by no means exempt, as was formerly supposed; on the contrary, I have 
repeatedly had an opportunity of observing, in my consultation practice as 
well as in the hospital, that nurslings are frequently and very seriously 
attacked by this affection. Boys are almost as frequently attacked as girls; 
there is no difference in sex regarding predisposition. 

It can hardly be maintained that season and weather influence the fre- 
quency of the disease. Whooping-cough occurs in summer to the same extent 
as in winter, with the difference that the winter epidemics are more tenacious 
and more serious, as complications on the part of the respiratory organs occur 
more readily in winter and thus produce a severer form of the disease. 

The disease is an infectious, transmissible one. 

Much discussion is noted in literature regarding the cause of the dis- 
ease. The question of a pathogenic agent is discussed as much to-day as at 
any time; each day bringing fresh investigations, new discoveries — unfortu- 
nately too many — and what is even more serious, no two that coincide. I 
shall only mention, to complete the discussion, that all sorts of schizomycetes, 
such as fungi that grow upon orange-skins, have been supposed to be related 
to the disease, that long, anerobic rods (bacilli) have been looked upon as the 
pathogenic agent, and that for example, Afanasieff is said to have produced 
the disease artificially in animals with these rods. I must mention that a 
specific diplococcus, cultivated from the sputum, has been described as the 
pathogenic agent and that the numerous authors who have made these dis- 
coveries are still discussing the identity of all these findings. Thus, lately, 
a small pole-bacterium, which occasionally occurs in short chains, described by 
Arnheim, which appears to be identical with one previously observed by Cza- 
plewski and Hensel in culture and biological behavior; it is quite probable 
that in numerous cases of whooping-cough this bacterium may be present. 
Nevertheless there are many doubts regarding these findings, and above all 
the etiologic importance has not been proved. The relation of all these dis- 
coveries becomes even more questionable, since a new bacillus has been lately 
described by Jochmann, which is said to be closely allied to the influenza 
bacillus (Pfeiffer), perhaps is identical with it, and, as the author expresses 



PATHOGENESIS AND ETIOLOGY 777 

himself, " must be first considered in investigating the etiology of tussis-con- 
vulsiva, as the bacillus is constantly found in the expectoration of whooping- 
cough during the convulsive stage." I may further mention that Deichler, 
in the year 1886, found protozoa-like structures in the expectoration of 
whooping-cough patients, which he believed to be the pathogenic agents; and 
thus quite a number of microbes have been etiologically suspected from which 
a choice may be taken according to option, or, what appears to me to be more 
preferable, it is better to remain a skeptic, or what is even better, every physi- 
cian should himself search for the concealed, mysterious germ of the 
disease. 

It must not be thought that an attempt has always been made to clear the 
uncertainty of this curious disease from the standpoint of contagion. More- 
over, an attempt was made originally by physiology to search for the causes 
of the cough, to find the point of development of the disease. We know that 
the superior laryngeal nerve is the nerve which produces cough and that the 
posterior wall of the larynx, below the vocal cords, is the region from which 
most readily, intense cough may be produced. We have learned to recognize 
the severe reflex cough due to irritation of the nasal mucous membrane in 
which the fifth nerve is affected, and we were inclined to look upon these 
points as the actual seats of the pathologic changes which produce whooping- 
cough; the last mentioned area, all the more, as cases of whooping-cough are 
observed in which severe attacks of sneezing simultaneously accompany the 
cough. In fact we are able to observe, and this has been particularly described 
by Mayer-Huni and v. Herff, that the larynx, particularly, however, the 
entire posterior portion, the inter-arytenoid mucous membrane, shows a catar- 
rhal condition and inflammatory changes; the nasal mucous membrane and 
the tracheal mucous membrane, so far as they are accessible to direct investi- 
gation, are the seat of quite decided inflammatory irritation and swelling 
during the course of the disease. Thus there is a certain anatomic basis for 
the disease — inadequate and unimportant in comparison to the severity of 
the symptoms — and in connection with our experience of the positive trans- 
missibility of the disease we can hardly explain the condition differently, than 
by assuming that the disease is due to an infectious germ, causing catarrh of 
the upper respiratory passages, thus considering whooping-cough among the 
infectious, catarrhal diseases. Whether any of the previously mentioned 
microbes, that have been found in the mucous membrane inflammation, are 
the pathogenic agents or whether we are always dealing with the same one, 
which I believe to be extremely likely on account of the characteristic nature 
of the cough, cannot be decided in any direction at present. 

Thus it is noticed how etiologic investigation, begun at the bedside, search- 
ing for the cause of a disease, leads us from clinical observation ; this is quite 
natural in dealing with an infectious disease, the etiology of which has not 
been cleared up, for we are actuated by the thought, that with the discovery 
of the cause of the disease, the possibility of combating and controlling the 
affection will be attained. 



778 PERTUSSIS, WHOOPING-COUGH, TUSSIS-CONVULSIVA 

INDIVIDUAL SYMPTOMS AND COURSE 

The character of the disease, in the history just quoted, was uncomplicated; 
but particularly for this reason it was calculated to show the nature of true, 
uninfluenced whooping-cough. It was noted that the actual attack of cough 
was capable of division into two parts, that the first was followed by a second 
one, and I may mention that sometimes a third follows the second. This is 
characteristic of whooping-cough and the repetition of the attack is called 
" reprise," or whoop ; this hardly occurs in any other form of cough and from 
this alone whooping-cough may be recognized from other severe attacks of 
cough; thus from those due to enlarged bronchial glands, or that form of 
cough due to adenoid vegetations in the naso-pharyngeal space, etc. Whoop- 
ing-cough, as a rule, does not at once begin with severe attacks of cough, still 
less with the characteristic " reprise." The disease develops as a simple 
catarrh and this is also the mode in which the affection began in the patient 
whose history has just been quoted. However, from the beginning the cough 
has an extraordinarily severe character; there is a peculiar, intense, severe 
irritation which brings about the cough so that the children become dark-red 
in the face while coughing, even if but few paroxysms of cough follow the 
irritation. There are no physical signs in the thorax which correspond to this 
severe cough. The respiratory conditions are normal, there are no rales or 
other signs of catarrh. More and more these irritative phenomena increase, 
becoming more severe, so that a few attacks of cough no longer relieve them 
and paroxysms of cough develop so that an actual attack occurs. Simultane- 
ously the individual attack which now gradually takes on the character of the 
reprise just described, brings up a mucous, glassy, foaming secretion, quite in 
contrast to the usual condition in children who, as is well known, scarcely ever 
expectorate sputum. 

Thus we speak of a first {primary) catarrhal stage of whooping-cough. 
Soon other symptoms are added which impress upon these attacks of cough 
a severe, threatening character. It will be observed that children under the 
influence of these expiratory attacks of cough gradually suffer for want of 
air, there is insufficient time for inspiration, moreover it appears as if expira- 
tion will not cease, due to the paroxysms of cough which constantly become 
shorter and more superficial. The face, which is more and more turgid, 
becomes dark-red, soon even cyanotic; the lips bluish, the small vessels of the 
conjunctival mucous membrane appear filled with blood, the veins of the face, 
of the temples and of the neck stand out prominently, like dark bands filled 
with blood; finally, respiration ceases entirely with the cough, in deepest 
expiratory position the thorax rests in apnea; finally, with a loud, sighing, 
whistling sound a new inspiration occurs and slowly, with profuse expectora- 
tion of mucus masses and vomiting of the contents of the stomach, deep 
inspiratory movements occur, interrupted by attacks of cough, completing 
the first part of the attack, followed by a second and even a third of almost 
like severity and of the same character. 



INDIVIDUAL SYMPTOMS AND COURSE 779 

This respiratory spasm and the apnea which are due apparently to the 
deepest expiration with closed glottis, have impressed the name tussis-con- 
rulsiva to the cough in this stage of its development, and the phase of the 
cough has heen designated as the convulsive stage. Quite properly, for there 
are a number of cases in which in the same phase of the cough, during the 
apnea and in connection with laryngospastic conditions, actual clonic and 
tonic spasms occur of a severe epileptiform character with complete loss of 
consciousness and all the phenomena which go to make np the eclamptic symp- 
tom-complex. "With these symptoms whooping-cough has reached the acme of 
its development; nor is there a limit for the number of the daily and noc- 
turnal individual attacks. For weeks the cough may remain of the same 
grade of severity and 30-40-60 attacks may occur in the afflicted children 
which have a deleterious effect upon their nutrition, exhausting their strength, 
until unfortunately not so rarely, the organism succumbs to these conditions, 
or complications severely threaten the youthful life. It is true many recover, 
probably the majority of children affected even with the severest forms of the 
disease. However, among those who recover there are not a few who for life 
suffer from chronic invalidism, showing exhaustive conditions on the part of 
the heart, such as dilatation of the cardiac ventricles, emphysema of the 
lungs, bronchiectasis with chronic catarrh, and bronchial adenopathy, besides 
all varieties of neurotic conditions and many other sequels which will be con- 
sidered later on. 

Finally, when the severity of the disease begins to decline, either spon- 
taneously or from the influence of therapeutic or hygienic measures, true 
catarrhal symptoms become more and more prominent; the attacks of cough 
become less severe, the spasmodic symptoms less frequent and milder, the 
tenacious sputum more yellowish, nummular, purulent — sputum coctum of 
the ancients — whereas simultaneously catarrhal phenomena of all kinds may 
be noted in the chest by the presence of profuse rales, denoting the develop- 
ment of the second catarrhal stage. The attacks of cough become rarer and 
rarer, appearing only now and then in rapidly passing moments, so that after 
weeks or months, they only indicate that the child has recovered from a 
severe infectious coughing disease. 

From this brief description it may be noted that the character of the 
disease is a severe one. Before considering the complications and sequels of 
whooping-cough some of the most prominent symptoms in the pathological 
picture will be described somewhat more in detail. 

In observing a case of whooping-cough it will be noted that with every 
attack of cough the child has been forced to open the mouth quite wide and 
to protrude the tongue; in small children this is particularly marked and as 
they, as a rule, have very sharp and relatively well developed anterior incisor 
teeth in their lower jaw, the frenum of the tongue is readily injured upon the 
teeth when the tongue is protruded; thus under the tongue a small sublingual 
ulcer develops, at first showing a fibrinous coating, which for a while was 
looked upon as a characteristic symptom of whooping-cough. This is, how- 



780 PERTUSSIS, WHOOPING-COUGH, TUSSIS-CONVULSIVA 

ever, not the ease; it is nothing more than the expression of a mechanical 
disturbance which' may occur in any disease accompanied by severe attacks of 
cough, and has nothing directly in common with whooping-cough and by no 
means is characteristic of it. 

Another condition which is readily noticed is the fact that particularly 
small children with rickets, with their already deformed soft thoracic skeleton, 
suIIVt very severely under the influence of whooping-cough. Under the influ- 
ence of the intense expiratory excursus the thorax almost appears collapsed 
dining the dyspnea and apnea. It should be remembered that these children 
are readily attacked by catarrhal diseases of the lungs and bronchi, that they 
are very liable to laryngospastic symptoms and thus it will be easily under- 
stood how great the danger to life in these children when attacked by whoop- 
ing-cough. As a matter of fact the majority of these poor, weak children 
succumb, if the disease be at all severe. 

Another category of children who do not possess especial resistance of 
the blood vessels, in pale and weak anemics, the effects of these severe attacks 
of cough may be noted from numerous effusions of blood. In such patients 
it will be seen that hemorrhages occur into the conjunctival mucous mem- 
brane, into the subcutaneous cellular tissue, even from the ear, and, although 
rarely, from the bronchial mucous membrane, and from the lungs in the 
form of hemoptysis; hemorrhages into the brain shall be considered later on, 
for they also occur. The subconjunctival hemorrhages which occasionally 
cover the entire eye and alarm the relatives of the child, as the eyes of the 
child attain a peculiar appearance, rapidly disappear by absorption of the 
effused blood, the condition being without importance, much less so than the 
hemorrhages from the ear or hemoptysis. 

It is to be expected a priori and is readily understood that in the same 
manner, as a consequence of the mechanical disturbance from these severe 
expiratory explosions, other anomalies occur in the infantile body such as 
umbilical hernias/ inguinal hernias, prolapse of the rectum, and general 
cutaneous emphysema, which although quite rare, I have myself observed and 
is worthy of note. [Intussusception in rare instances. — Editor.] 

Quite a number of more or less bothersome disturbances complicate whoop- 
ing-cough without actually having anything in common with the character of 
the same as an infectious disease ; naturally they are not to be looked upon 
too lightly; and yet they are subordinate to the other complications which 
develop upon the infectious basis of the disease. 



COMPLICATIONS AND SEQUELS 

We shall consider some of the most important of this second group. It 
will be impossible for me to mention all of the complications which occur but 
I shall quote from my own experience and from the literature the most 
prominent of these. 



COMPLICATIONS AND SEQUELS 781 

Case History. — A child, aged one and one-half years, almost moribund, with marked 
cyanosis even of the hands and finger-nails, dyspnea, in collapse, apparently unconscious, 
which but a few moments before was attacked by severe convulsions. In this condition 
the child was brought to the hospital and the physical examination reveals, bilaterally, 
especially posteriorly upon the left side of the chest, loud diffuse rales, particularly 
in the scapular region; in the same region bronchial respiration was noted. We were 
therefore dealing with a severe, diffuse bronchitis and with a large bronchopneumonic 
focus of the left lung, probably of both lungs. The temperature of the child was not 
above 101° F. The respiration was superficial and frequent, scarcely countable. The 
history showed that the child had been suffering from whooping-cough for some weeks; 
for a few days the symptoms of inflammation of the lung had been added, since which 
time the attacks of cough have become less frequent; in place of this, however, severe 
convulsions have occurred. We hardly hoped to save the child and this history is 
quoted to show that bronchitis and bronchopneumonia represent the severest danger 
in pertussis. 

The conditions were little better in a second case: A boy aged one year; the history 
shows that for fourteen days he has suffered from whooping-cough. Three days ago 
fever began and upon admission to the hospital, a temperature varying between 101° F. 
and 103° F. was present with excessive dyspnea. In this case diffuse rales also were 
noted over the entire thorax and a quite extensive area of dulness over which bronchial 
respiration could be determined was found in the right scapular region. This child 
also had two general convulsions in one day; the child was unconscious and strabismus 
was noted. An unfavorable prognosis was given in this case. It is noteworthy that 
severe attacks of whooping-cough were observed in the child even in this condition. 

Bronchitis and bronchopneumonia are in fact the two complications which 
develop from the infectious character of whooping-cough, and may perhaps 
themselves be designated infectious diseases, but when superadded to whoop- 
ing-cough lend malignancy to the character of the affection and cause the 
death of young children. The danger in older children is not so great. How- 
ever, the disease is severe enough and pulmonary inflammations complicating 
whooping-cough are to be feared under all circumstances; even in older chil- 
dren serious sequels remain: Atelectases of the lungs which are difficult to 
overcome ; emphysematous areas at the border of the lungs ; chronic bronchitis 
with a tendency to bronchiectasis, and what is more serious, with a tendency 
to softening of pulmonary areas under the influence of specific or saprophytic 
bacteria, such as the tubercle bacillus or the bacillus tetragenus and strep- 
tococcus. Thus after years, bronchiectasis and tuberculosis may end the life 
of a child particularly when complete convalescence from the original disease 
has not taken place. 

It will be noted that in the first case it was mentioned that the attacks of 
whooping-cough ceased with the appearance of pneumonia ; this is frequently 
the case but not necessarily so, as is taught by the second case in which the 
attacks continued in spite of the pneumonia. I have already called attention 
to the importance of convulsions. In such instances they were the accom- 
paniment of the general infection from pneumonia. But even without this, 
convulsions are serious additions to whooping-cough, and this is true even in 
older children, for this complication, which is very serious, often in a few 
days causes the death of the child. Probably here also the general infection 
is the source of the convulsion, for as we shall learn further on, the con- 



782 PERTUSSIS, WHOOPING-COUGH, TUSSIS-CONVULSIVA 

tagium of tussis-convulsiva lias a toxic-malignant character. Convulsions may 
also occur from the combined action of several pathogenic agents under the 
influence of increased temperature. 

Convulsions may also occur due to other causes, thus from an accompany- 
ing nephritis which gives rise to uremia. Many years ago, in a discussion in 
the Berlin Medical Society, I called attention to the fact that every infectious 
disease of childhood, even a subacute or chronic eruption, might be accom- 
panied by nephritis; thus nephritis is by no means a rare occurrence in 
whooping-cough. I have lately had the opportunity of seeing several cases of 
nephritis occurring in the course of pertussis, fortunately without uremic 
convulsions. 



Case History. — A well developed girl suffering for a few weeks from a severe attack 
of whooping-cough frequently accompanied with vomiting. The face is somewhat turgid, 
the eyelids are swollen so that the bulbi can be seen with difficulty ; the internal organs 
present nothing that is pathologic, however, the child is feverish, the temperature vary- 
ing between 99.5° F. and 104° F.; the composition of the scant urine is conspicuous 
in that on some days it does not amount to more than 130 c.c. with a specific gravity 
of 1,020, on other days amounting to 400 c.c. The urine is turbid, of a light brownish 
red color, containing albumin, some few blood corpuscles, large numbers of casts mostly 
hyaline, beside numerous leukocytes. This presents a form of acute nephritis which 
could not be more typical than as a sequel of scarlatina. It is quite obvious that such 
a nephritis may also present a uremic symptom-complex, and I have noted this condition 
in a similar case in which a fatal termination occurred. The case was one of a well- 
nourished strong girl aged three who developed severe convulsions in connection with 
a marked case of whooping-cough; the spasms recurred frequently and did not yield to 
sedatives nor to venesection. The child hardly had an opportunity of recovering from 
its soporose condition, partly due to the influence of the dreadful attacks of whooping- 
cough which recurred twenty times daily and were accompanied by convulsions, partly 
also on account of uremic intoxication; for three weeks we had an opportunity of 
observing this case, which finally terminated fatally on account of the repeated con- 
vulsive attacks. Unfortunately it was impossible for us to obtain an autopsy, so that 
the question had to remain open as to whether certain changes of the brain (hydro- 
cephalus?) were responsible for the lethal outcome. 



From this it is evident that nephritis represents a serious complication of 
pertussis and that we have good reason for devoting our attention to this com- 
plication. 

Certain anomalies of the heart also require observation; in my text-book 
I mentioned the occurrence of sudden death due to cardiac collapse and un- 
questionably changes of the heart muscle play a certain role in this condition. 
If the cases are observed, which succumb after the disease has lasted a long 
time, degeneration of the heart muscle can often be noted. This was described 
by Silbermann many years ago. I have also observed this condition, but the 
minute study of these degenerative changes has not yet been concluded. It is 
evident that besides the probable direct toxic action of the poison of whooping- 
cough upon the heart muscle, the powerful stasis in the right heart which is 
due to the attacks of cough, is capable of damaging the heart muscle: all the 
more so if the children, under the influence of frequent vomiting and insuffi- 



COMPLICATIONS AND SEQUELS 783 

cient nourishment, suffer more and more in their nutrition, becoming feeble 
and anemic. 

In the course and in connection with tussis-convulsiva the most remarkable 
and rare diseases of the nervous system occur which require careful consid- 
eration. They are not common, but I am able to speak from my own experi- 
ence and report some very peculiar pathologic conditions. 

The first case which called my attention to the peculiar disturbance of the 
nervous system, most probably due to the toxic effect of the poison of whoop- 
ing-cough, was the case of the three year old daughter of a lawyer, who was 
brought to me in a most remarkable condition. A robust, strong child who 
had suffered from severe whooping-cough for weeks, suddenly presented a con- 
dition — I can scarcely express it differently — resembling the brute creation. 
Everything that characterizes a hitman being had disappeared in the child. 
Without speech, without sight and hearing, without taste, the child snapped 
at everything with which it came in contact in a stupid and insane manner; 
senseless and uninfluenced by its surroundings the child gave forth roaring 
sounds, feeling its way from place to place, running into everything and with- 
out the slightest sense of perception; even the property of mastication was 
lost and only with the greatest difficulty could the poor, unfortunate child, 
which had almost become brutal, be nourished. In this pitiable condition 
the child remained for weeks and only very gradually did a return to normal 
occur in that signs of the sense of perception by sound, curiously showing itself 
in attention to music, then of smell and sight reappeared. Gradually the 
sensorium became free so that the child showed a sense of recognition for its 
surroundings. After the ice had once been broken the return to a normal psy- 
chical condition was surprisingly rapid, and I was able to return the child to 
the happy father completely cured. The child showed no motor disturbance. 
The entire process affected the sensory and psychical spheres. 

I observed two cases in the hospital which were not quite so characteristic 
but nevertheless important; I have mentioned them briefly in my text-book 
but shall be a little more explicit at this point. 

A boy aged three and a half, well nourished, was admitted in January, 1897. Three 
weeks before his admission to the hospital he had suffered from attacks of whooping- 
cough, which prior to admission were combined with general spasms (convulsions). 
Upon the day of admission there was high fever, almost 104° F., which disappeared in 
the next few days so that the temperature dropped to normal. In the following night 
severe spasms occurred beginning upon the left side, in the region of the facial nerve, 
and affecting the nerves of the arm, soon distributing themselves to the right side and 
finally, after a severe attack of cough, disappearing. After a number of relatively good 
days in connection with attacks of cough, severe crying spells occurred, apparently 
produced by hallucinations of fear, the child assuming an expression of decided fear, 
constantly exclaiming " to bed, to bed," whereas in fact he was in bed. Attempts at 
quieting him were entirely ineffectual; only very gradually did he become calmer; how- 
ever, the exclamations of fear and cries repeated themselves during the night; finally, 
the child slept, awoke upon the next morning with a clear mind and remained so in 
the .further course of the whooping-cough, which gradually disappeared; the child 
remained free from similar attacks. The child was discharged cured. 



784 PERTUSSIS, WHOOPING-COUGH, TUSSIS-CONVULSIVA 

In this case we were dealing with a psychical alteration closely allied to 
the well known pavor noclurnus of children, only with the difference that the 
terror did not occur during the night. 

The third case closely resembled the first one described and occurred in a girl aged 
two, admitted in December, 1897. Prior to admission the child suffered for six weeks 
from whooping-cough accompanied by convulsions; under the influence of these condi- 
tions the child lost the sense of recognition for its surroundings and for this reason was 
brought to the hospital. The child was well nourished but showed itself as completely 
unconscious of its surroundings. The eyes, with the wide staring pupils were directed 
into space; with this there was rigidity of the muscles of the neck with slight opis- 
thotonus; spasm in the somewhat spastic upper extremities and in the fingers, move- 
ments of mastication, deep sighing and occasional moaning, and loud screaming. The 
child had a normal temperature, pulse being from 96 to 100 in a minute. During the 
next days the child showed a more and more almost brutal, stupid condition. Bleating 
with suppressed voice; unmotived movements of resistance with hands and feet, with a 
disturbed position of the extremities when a more quiet condition occurred; taking 
of nourishment in a greedy, hasty manner; complete apathy for the surroundings so 
that the child when taken up stared; when placed in bed it bored its face in the pillows 
while the trunk and buttocks were directed upward almost in an irregular knee-elbow 
position. Very gradually and slowly did the condition of the child improve and the. 
mind become freer so that the child occasionally sat up and showed some sense of percep- 
tion for its surroundings; when asked to shake hands it only slowly and hesitatingly 
complied " as if a veil covered the consciousness of the child," as the history remarked. 
With this the facial expression appeared serious and not childlike. Finally, the child 
became pleased with the ticking of a clock; slowly and with isolated sounds did speech 
return, at least to the extent that the child repeated words, speech up to then having 
disappeared completely. With this improvement of the mind the attacks of whooping- 
cough which had persisted and which were still quite severe, finally ceased and the child 
was discharged from the hospital in a greatly improved condition. The case recovered 
completely. 

The similarity of this case to the one first reported is obvious, and as it is 
not likely that any serious anatomic lesion was the foundation of these peculiar 
psychic alterations, which, however, finally disappeared with relative rapidity, 
we may either consider an edematous transudation of the cerebral hemispheres 
due to the influence of the severe attacks of cough, or a toxic influence of the 
brain due to the toxins of whooping-cough as the source of the nervous psy- 
chical disturbances. It is true in the last case, at the onset of the disease, there 
were certain symptoms pointing to a meningo-encephalitic irritation, such as 
rigidity of the muscles of the back of the neck, spasm, etc. ; but on the other 
hand fever was absent so that a marked inflammatory infection of the meninges 
was not likely. 

Nevertheless the cases are quite remarkable and medical literature is not 
rich in similar communications ; however, other cases are mentioned which may 
be counted in this category and will aid to impress some of our observations. 

Thus in literature there is a case of sudden blindness reported by Alexan- 
der and the author regards the cause of this condition to be due to a menin- 
geal irritation produced by cerebral edema and so, also, other cases of disturb- 
ance in sight, due to probable cortical lesions of the brain, characterized as 
sensory affections under the picture of " soul blindness." 



MIXED INFECTIONS 785 

It is not surprising that under the influence of these severe attacks of 
cough, occasional hemorrhages may occur into the brain with the characteristic 
symptoms of cerebral apoplexy, hemiplegia, loss of consciousness with suc- 
ceeding spastic unilateral paralyses, which only very gradually but neverthe- 
less completely disappeared without producing a permanent damage to the 
affected child, but nevertheless are only with great difficulty corrected by 
orthopedic manipulation. 

Stranger than these forms of paralysis are others due to serious lesions of 
individual areas of the brain and spinal cord, which either terminate fatally 
or produce a permanent damage to the infantile organism. 

Thus I saw a case of typical, ascending, Landry's paralysis with a rapid, 
fatal termination in a boy, occurring in connection with whooping-cough; I 
still see him before me, a pale boy about seven years old, brought to my office, 
who collapsed completely in attempting to walk after a few staggering steps, 
and in the next few days being completely paralyzed with exquisite symptoms 
of a bulbar affection giving rise to difficulty in deglutition and respiration; 
thus there are individual cases of spastic spinal paralysis, of encephalitis with 
paraplegic symptoms, of multiple sclerosis, with beginning bulbar symptoms 
and later spastic paralytic condition, of polyneuritis with parasthesia, anes- 
thesia and j3aralysis. 

These sequels upon the whole are isolated when compared with the great 
frequency of whooping-cough in general, but they are calculated to show the 
affection as a serious and dangerous one. 

I may refer, for other cases from my clinic, to an article by one. of my 
assistants (May) in the Archiv fur Kinderheilkunde in regard to nervous 
affections of this form. 

In what manner these complications occur is entirely unknown on account 
of our lack of knowledge of the pathogenic agent of whooping-cough; it is 
hardly possible to refer all these conditions alone to mechanical causes, hem- 
orrhages, edema and the like, and we are forced to think, the more such 
cases are observed, that similar to the condition in diphtheria, a toxic sub- 
stance generated by the pathogenic agent circulates in the blood, as in the 
case of diphtheria, which affects the nervous tissue causing slight repairable, 
or also severe, unchangeable alterations; with the assumption of a toxic sub- 
stance we are able to explain the peculiar observation which, as a rule, is noted 
in whoojnng-cough, the hyperleukocytosis. 

MIXED INFECTIONS 

As I have mentioned diphtheria, it is unfortunate that in whooping-cough 
other infectious diseases can be by no means excluded, that, moreover, com- 
binations of pertussis with other infectious diseases bring about mixed infec- 
tions, this being by no means of rare occurrence; thus we commonly find 
pertussis in combination with measles in young children, and also with scar- 
latina and diphtheria; the terrible condition mav be imagined of a simultane- 
51 



786 PERTUSSIS, WHOOPING-COUGH, TUSSIS-CONVULSIVA 

ous diphtheria and whooping-cough in a child in whom, en account of a 
croupous, laryngostenotic affection a tracheotomy has to be performed, the 
cannula being kept in place and dreadful attacks of cough occurring — or in a 
case of measles, which is accompanied by bronchitis, the painful condition 
of whooping-cough being superadded. It is not to be wondered at, if these 
children succumb, with the symptoms of exhaustion or if pulmonary atelec- 
tasis or bronchopneumonia occur. Among the complicating diseases we also 
find, and not particularly infrequently in little children, otitis media, this 
being b} r no means a harmless and painless affection, for it frequently threatens 
life on account of its general effect when occurring in the course of whooping- 
cough. 

After what has been mentioned it will readily be seen with what a dan- 
gerous disease we are dealing in younger children. In our statistics of infant 
mortality we reckon whooping-cough among those diseases which show a de- 
cided influence in the general mortality. 

PROGNOSIS 

From the statistics of the city of Berlin, only to mention this one city, 
we are able to note that in the years from 1890 to 1899 (ten years) the 
mortality in children from whooping-cough amounted to 4,868; among these 
more than half, 2,619, occurred in the first year of life. From the mortality 
tables calculated per thousand, in the population of Berlin, it will be noted 
that in the years from 1885 to 1896, 9.54 per thousand occurred from pertus- 
sis, greater than measles, which only amounted to 6.88 per thousand, and even 
more than scarlatina, which amounted to 7.83 per thousand. Thus there is 
every reason for fearing this disease. 

The prognosis becomes more serious if complications are added, or pre- 
ceding disease or constitutional anomalies, influence the health of the child; 
thus children with old caseous, tuberculous foci are in great danger, as well 
as children with old pleuritic adhesions, with still existing or previous rickets, 
syphilis, etc. Above all, the youngest children are threatened and for an 
infant there is perhaps no more dangerous serious combination than rickets 
with whooping-cough. It will be noted, from my explanation, that the direct 
danger to life is not all that is to be considered; that dangers may exist in 
other directions, in that many children become permanent invalids or only 
recover with great difficulty, to finally succumb to tuberculosis; many retain 
pulmonary emphysema, a weakened heart, others nephritis, others all kinds 
of mechanical lesions such as umbilical hernia, inguinal hernia or nervous 
affections, paralysis, etc. In a word the prognosis of the disease is always 
serious. 

DIAGNOSIS 

The diagnosis does not give rise to difficulties. At the most, at the onset 
the disease may be difficult of recognition until the characteristic attacks of 



PROPHYLAXIS AND THERAPY 787 

cough with a whoop and vomiting occur. If a genuine attack has ever heen 
noted the diagnosis becomes certain ; wherever there is doubt the signs of a 
severe attack of cough with an almost negative condition in the thorax, and 
the fact that the attacks occur particularly during the night, which is a very 
rare condition in simple catarrhal respiratory diseases, will aid the diagnosis. 
There are two varieties of disease with which whooping-cough may be con- 
fused : the cough which accompanies chronic pharyngeal catarrh and adenoid 
vegetations, and that form of cough produced by bronchial adenopathy. The 
first of the two affections may be readily recognized by an examination of the 
pharynx; the second is more difficult; nevertheless, even here, enlargement 
of the cervical lymph-glands and the physical signs obtained upon ausculta- 
tion and percussion upon the posterior aspect of the thorax, offer points of 
support for the diagnosis; in the main, however, attacks of whooping-cough 
are so characteristic that they are even familiar to laymen and finally the 
presence of a hyperleukocytosis in doubtful cases will decide in favor of whoop- 
ing-cough. 

PROPHYLAXIS AND THERAPY 

The early recognition of the disease is certainly of great importance. Un- 
fortunately more for the friends and relatives of the patient than for the 
patient himself; for even with an early diagnosis we are incapable of abort- 
ing the cough or influencing its course; but the surroundings of the patient 
may be protected by removing and isolating the affected individual. This 
is of especial importance in schools, for we are thus able to prevent the patient 
from attending school and thus distributing the disease. As a matter of fact 
the prevention of contact and holding at a distance is the only prophylaxis in 
whooping-cough; there is no other protection of which I am aware. Even 
more than the prophylaxis is the therapy of the disease limited, and, as we 
may frankly admit, helpless. 

Up till now there is no active therapy of whooping-cough, although every 
da} r , air bubbles of therapeutic successes are exploded. Unfortunately now, 
more than ever, pharmaceutical industry is busy in forcing remedies upon 
us; up till now, all without effect! Whether we prescribe reputed specific 
measures, which are none, like pertussin — a sweetened thymus extract or ex- 
tract of chestnuts, antibacterial remedies of a general nature such as carbolic 
acid, thymol, resorcin and many others, whether these remedies are adminis- 
tered internally or externally, no matter, they are and remain without effect. 
The attempt has been made a hundred times to hang cloths dipped in carbolic 
acid over the beds of children; occasionally amelioration is said to have oc- 
curred; according to my experience it is entirely without result; the same 
is true of inhalations of oil of turpentine, naphthalan, petroleum, nitrite of 
potassium, tincture of eucalyptus, gazeol steam, sulphurous acid, etc. This 
only tortures the children ; we accomplish nothing with these remedies, for the 
disease progresses uninfluenced if it does not even show a deleterious effect, as 



788 PERTUSSIS, WHOOPING-COUGH, TUSSIS-CONVULSIVA 

occasionally after the use of naphthalin, in that the respiratory organs show 
an inflammatory reaction and bronchitis develops. 

I do not intend to mention the entire army of these useless remedies but 
only to speak of a few which have a somewhat favorable action. First is the 
extended use of fresh air; the more we are enabled to allow the children to 
remain in the fresh air the more readily do they overcome the disease; for this 
reason the children are sent into the woods, to the seashore and to the moun- 
tains, hence it is advisable to send the children to a different locality; un- 
fortunately to the detriment of those localities to which the children are 
brought as the germs of the disease are carried from place to place. If in a 
cold climate, during the winter, it is impossible to use the treatment by fresh 
air we should see to it that the rooms of the children are well ventilated, the 
child often being removed from one room to another, to keep away the conta- 
gium which is distributed in this manner from the surroundings of the child. 

Among drugs only two groups are to be considered ; the one of a somewhat 
antifermentative, antizymotic character, and here quinin and quinin deriva- 
tives take the front rank. The salts of quinin in doses of 0.1-0.3-0.5 per dose 
two to three times daily, euchinin, which has no bitter taste in somewhat 
increased doses (1J grams corresponding in action to 1 gram of the quinin 
salt) in some cases of whooping-cough have a decided action and serve simul- 
taneously as a tonic, assisting the constitution of the child. With great care 
the preparations of salicylic acid, such as aspirin, antispasmin, are to be em- 
ployed, as salicylic acid is capable of exerting a deleterious effect upon the heart 
muscle. 

The second group of remedies includes all those which have a sedative 
effect and diminish irritation; here the first place is taken by morphia itself, 
then codein which perhaps is better borne by children than morphia; extract 
of belladonna, chloral hydrate, phenocollum hydrochloricum and the greatly 
praised antipyrin which occasionally is of decided effect; finally the entire 
list of bromin combinations, among which bromoform has lately taken the 
front rank. Bromoform, according to the age of the child, in from 3 to 5 to 
10 drops three times daily, is a convenient method of administration and with 
some care also a harmless remedy, which is capable of diminishing the attacks 
of cough and thus perhaps to shorten the duration of the disease. With these 
remedies, which must be changed frequently, and combined with others, we 
are able to offer some relief. Of all the other remedies formerly and lately 
advised I scarcely employ any, nor of the anti-irritative remedies which were 
advised upon theoretical grounds such as insufflation into the nose with benzol, 
calomel, boric acid, etc., and I only use these remedies if severe attacks of sneez- 
ing accompany the cough. 

I need hardly add anything further in the treatment; in severe nervous 
conditions, in irritative conditions of the brain, meningitis, cerebral hemor- 
rhage and other effusions of blood, in nephritis, in a complicating bronchitis 
and pneumonia, the remedies usually employed in these conditions are of use 
here; severe and repeated vomiting requires especial observation and besides 



PROPHYLAXIS AND THERAPY 789 

small doses of morphia or codein the preparations of bismuth are capable of 
ameliorating and perhaps improving the condition. I need not mention nurs- 
ing nor diet in this disease. 

The children should be well nourished, according to their age and power 
of digestion. Meat juice, tropon, plasmon and foods of this kind may be used 
from time to time. Finally, after recovery from the disease hygienic measures 
must be employed to strengthen the child ; after recovery a prolonged residence 
in a warm climate, such as a southern sea-coast, will certainly be of advantage 
if the physician is able to send his patient there. 

[Convulsions must not be permitted to last any length of time. Any attack 
may be fatal, or at least give rise to an intracranial hemorrhage, with injury to 
the brain, hemiplegia, etc. Chloroform should be handy and be used at once. 
Many years ago I published a case in which it was used thirty times a day, 
and the presence of the physician was required several days in succession, with 
favorable results. 

The author mentions belladonna ; but not in the impressive way it deserves. 
It has been recommended from time to time during the nineteenth century 
and given up as useless. The reason for this is the faulty method of its admin- 
istration. I have used it more than half a century, and know of nothing better, 
or equally as good. Take the case of a child of two years: Give 6 drops of 
tincture of belladonna, 3 times a day. Unless the drug cause a " feverish " 
flush on the cheeks within half an hour, which must last half an hour or more, 
it has no effect. If 6 drops have no such effect, give seven, eight, nine or more 
every time. The effect must be attained every time, 3 times daily. Give as 
many drops as are required to accomplish that end. After a few days more 
drops will be required. After about a week the full dose will probably have to 
be doubled. Throat and pupil symptoms do not annoy the young as they do 
the adult. If this be done persistently, whooping-cough will last as many 
weeks as months without it. Moderation of the cough will be observed within 
two weeks or less. As long as it is severe it will give rise to some complica- 
tions which the author pictures in his masterly exposition. The saving of 
those months means the saving of pneumonias, convulsions and acute or 
chronic or lifelong ailments caused by the treacherous infection. I am quite 
positive that the omission of an effective treatment of whooping-cough is sinful. 
— Editor.] 



INDEX OF AUTHORS 



Abbot, 464. 

Abel, 464. 

Abeles, 492. 

Abercbombie, 153. 

Adams, 556. 

Afanasieff, 776. 

Ahlfeld, 27, 28, 40, 62, 77, 78, 79, 104, 

121, 181. 
Albert, 562. 
Albu, 307. 

Alexander, 240, 784. 
Alexy, 503. 
Almquist, 105. 
Alt, 771. 
Alzheimer, 330. 
Anche, 16. 
Anders, 116. 
Anthes, 80. 
Anton, 578. 
Arend, 558. 
Aretaeus, 153. 
Arndt, 344. 
Arniieim, 776. 
Aronson, 755. 
Assmus, 10, 19. 
Astros, 319. 
Atjcher, 244. 
Aufrecht, 110, 744. 

AlJWARD, 15. 
AXENFELD, 92. 

Babeau, 247. 

Backhatjs, 15, 132, 276. 

Bader, 515. 

Baginsky, A., 112, 121, 154, 155, 162, 
163, 166, 192, 202, 204, 206, 243, 244, 
247, 280, 293, 295, 409, 434, 459, 464, 
468, 469, 475, 501, 506, 672, 731, 736, 
774. 

Bahrdt, 692. 

Ball, 259. 



Ballot, 214. 

Bamberger, 159. 

Band, 287. 

Bang, 305. 

Bar, 16, 32. 

Bardexheuer, 54. 

Barensprung, 27. 

Barlow, 217, 219, 223. 

Barrier, 153, 532. 

Bartels, 481. 

Barthez, 114, 260, 295, 462, 515, 516, 

519, 520, 532. 
v. Basch, 63. 
Baumel, 239. 
Baumes, 445. 
Baumgarten, 287, 288. 
Bayer, 564, 566, 569. 
Beck, 321, 455, 530, 538. 
Beclere, 769. 

Bednar, 153, 160, 241, 409. 
Behm, 34. 

Behrend, 66, 108, 327. 
Behring, 737, 755, 758, 760. 
Bein, 765. 

Bell, Charles, 396. 
Bendix, 181, 206, 211. 
Bendix, B., 570. 
Bendix, E., 527. 
van den Berg, 676. 
Berger, 446. 
Berghing, 324. 
v. d. Berghs, 208. 
Berkley, 579. 
Bertin, 173. 
Bezold, 498. 
Bezy-Bibent, 350. 
Biedert, 84, 154, 159, 161, 168, 244, 276, 

287, 292, 467. 
Biedl, 445. 

BlENSTOCK, 163. 

Billard, 153, 509. 

791 



792 



INDEX OF AUTHORS 



Billroth, 501. 

BlNSWANGER, 440. 

Binz, 113, 402. 

Birch-Hirschfeld, 10, 20, 21, 97, 98, 99, 

288. 
Blake, 498. 
Blaschko, 332. 
Bloch, 202, 491, 492. 
Blomberg, 105. 
Blumenthal, 103. 
bodenstab, 105. 

BOECKEL, 551. 

Boer, 155. 

Bohm, 072. 

Bohn, 100, 117. 

Bokai, Jr., 503, 505. 

Bokai, Sr., 500, 502, 500, 507, 527, 758. 

bollenhagen, 00. 

Bollinger, 280. 

Bonome, 454. 

Booker, 102, 103, 104. 

Boral, 430. 

Bordoni, 509. 

BORNTRAGER, 242. 

Bostock, 343. 

Botkin, 102. 

Bouchard, 240, 259, 403. 

Bouchut, 459. 

Bouchy, 579. 

Bourneville, 531, 532, 535. 

Bourson, 579. 

Boyer, 473, 544. 

Bradley, 322. 

Brasch, 330. 

Bratz, 330. 

Bresgen, 404, 407, 470, 477, 493, 494. 

Breslau, 124. 

Bretonneau, Pierre, 070, 731, 734, 737, 

749, 754. 
Bright, 582. 
Brindeatj, 142. 
Brindel, 495. 
Bristowe, 510. 
Broadbent, 578. 
Broussais, 153. 
Brouvier, 287. 
Brown-Sequard, 387. 
Brubacher, 240. 
Brudzinski, 170. 
de Bruin, 220. 
Bruning, 209, 581, 582, 585. 
Brunnengraber, 195. 



Bruns, 371. 
Budberg, 79. 
Budin, 02, 04, 131. 
Buhl, 114. 
Bulloch, 100. 
Bumm, 84, 85, 80. 
Bunge, 125, 229. 
Burckhardt, 503, 505. 
Burgh ardt, 248. 
Burmeister, 51. 
Burton, 709. 
BtissEM, 205. 
Buys, 404. 
Bystrow, 241. 

Cahen, 1G5. 

Caillault, 104. 

Camerer, 200. 

Carnot, 118. 

Carstens, 101. 

Cassel, 220, 227. 

Catrin, 705. 

Catti, 408, 498. 

Cazeaux, 27. 

Celli, 104. 

Cervesato, 454. 

Chambrelent, 10. 

Champineys, 34. 

Charcot, 539. 

Chartres, 92. 

Chaumier, 239, 248. 

Chantemesse, 19. 

Chavane, 131. 

Cheadle, 217, 224, 225. 

Chiari, 321, 457, 407, 408, 470, 471, 474, 

476, 477, 494, 495, 497, 498, 537. 
Chipault, 538. 
Cholmogoroff, 78, 79. 
Chvostek, 426. 
Claesen, 100. 
Clarke, J., 423. 
Cohn, 84, 89, 222, 239, 242, 244, 251, 252, 

259. 
Cohnheim, 99, 272, 285, 286, 287. 
Coindet, 521, 524. 

COLLOMB, 771. 

Comby, 257, 259, 261, 270, 280, 402, 438, 

442, 516, 586, 765, 771, 773. 
Concetti, 169, 404, 464. 
Conctoux, 494. 
de Confevron, 515. 
constans, 515. 



INDEX OF AUTHORS 



793 



Cornet, 289, 290, 295, 297. 
Corvisart, 423. 
Coutts, 440. 
Cramer, 90, 130. 
Crede, 15, 61, 88, 89, 90. 
Croner, 771. 
Cruse, 96, 97, 98. 
Cruveilhier, 153. 

CULMANN, 676. 

Czaplewski, 776. 

CZERMAK, 486. 

Czerny, 163, 200, 207, 208, 335, 405, 409. 

CZERWENKA, 80. 

Damaschixo, 591. 

Damm, 16. 

Dance, 423. 

Danyau, 60. 

D'Astros, L., 531, 532, 533, 536, 538. 

De Cerenville, 769. 

Deichler, 777. 

Delcourt, 247. 

Delpech, 541, 553. 

Demme, 106, 286, 291, 299, 402, 516, 766. 

Denis, 153. 

Dennig, 515, 520. 

Depasse, 320. 

Depaul, 60. 

D'Espine, 404, 408, 429, 430, 438, 446, 

516. 
Dewees, 154. 
Dickenson, 78. 
Dickinson, 275, 578. 
v. Didynski, 330. 
Dohle, 45. 
Dohrn, 80, 105, 106. 
Dollinger, 503, 506. 
Donders, 746. 

DORENDORF, 481. 

Doring, 670. 

Duchenne, 48, 57, 58, 746. 

Dufour, 446. 

Dukes, Clement, 613, 618, 619. 

Duplay, 244. 

Dupuytren, 486. 

Durk, 19. 

Ebert, 305. 
Eberth, 19, 509. 
Edlefson, 24.8. 
Ehrlich, 639, 755. 
Eichhorst, 769. 



ElSENLOHR, 578. 
ElSENMANN, 90. 

Elgood, 245. 

Elisciier, 578. 

Elliott, George T., 118. 

Elsasser, 111, 237, 241, 251, 260, 425, 

437, 442. 
Emminghaus, 519, 614, 618. 
Engelmann, 91. 
Epstein, 67, 73, 74, 80, 81, 98, 163, 164, 

165, 173, 236, 239, 265, 294, 409, 437. 
Erb, 57, 58, 61, 343, 345, 427, 433, 518, 

554. 
Ernst, 19, 20. 
Eross, 62, 67, 74, 77, 80. 
Escherich, 84, 124, 129, 263, 264, 409, 

414, 418, 426, 427, 428, 429, 431, 432, 

434, 437, 441, 443, 444. 
Esquirol, 536. 
Esser, 327. 

Eulenburg, 566, 574, 575, 580, 581. 
Ewart, 769. 

Faber, 105. 

Fabre, 515, 769. 

Fede, 238, 239, 242. 

Feer, 181, 238, 239, 240, 241, 243, 245, 

554, 556. 
Fehde, 202. 
Fehling, 90. 
Fein, 498. 
Feiss, 85. 
Felix, 488, 493. 
Fere, 445. 
Ferraris, 19. 
Feyerabend, 241. 
Fieux, 59. 

Filatow, 465, 574, 586, 587, 631. 
Filia, 455. 
Finger, 309, 464. 
Finkelstein, 15, 164, 165, 173, 183, 187, 

202, 207, 226, 233, 404, 431, 432, 439, 

452, 513. 
Fischbein, 439. 
Fischer, 506. 
Fischer, E., 543. 
Fischl, 164, 239, 242, 243, 247, 248, 250, 

256, 327, 330, 404, 704. 
Flechsig, 385, 398. 
Fleischmann, 155, 406, 530. 
Flesch, 439. 
Fliess, 471. 



794 



INDEX OF AUTHORS 



Flora xd, 514. 

Flugge, 674. 

Foa, 509. 

Ford, 515. 

Forest, 225. 

Korster, 31, 206. 

Fourxier, 325, 326, 332, 335, 470, 471, 

472. 
Fox, 259. 
Fraexkel, 509. 

Fraexkel, B., 464, 487, 488, 492, 494. 
Fraxk, 47, 764. 
Fraxkel, 20. 

Fraxkel-Weiciiselbaum, 591. 
Fraxkl-Hochwart, 432, 434. 
Freihan, 526, 529. 
Frexkel, 568. 
Frexkel-Leydex, 569. 
Frerichs, 100. 
Freud, 553, 554. 

Freund, 183, 188, 189, 206, 208, 326. 
Freymaxx, 10. 
Friedmann, 301. 
Fritsch, 39, 43, 44, 50, 54, 393. 
Froebeilius, 294. 
Frohlich, 259, 581, 582. 
Fruhwald, 282. 
Furbringer, 513, 530, 661, 709. 

Galvagni, 302. 

Gaxghofner, 426, 428, 431, 535. 

Gartxer, 15, 84, 132, 244, 276, 287. 

de Gassicourt, Cadet, 591, 748. 

Gautier, 765. 

Gay, 301, 429, 437. 

Gebhard, 31. 

Gexerali, 445. 

Gexersich, 192. 

Gexrich, 113. 

Gerber, 470, 471, 472. 

Gerhardt, 573, 766. 

Gesxer, 98, 102, 244. 

Geyl, 47. 

Ghon, 464. 

Gibxey, 561. 

Giese, 102. 

Gtuzetti, 579. 

Gley, 445. 

Glisson, 236, 237. 

Goelis, 515, 519. 

Goffroy, 539. 

Goldhammeb, 337. 



GOLDSCHMIDT, 513. 

Goi.tz, 394. 
Goppert, 192. 
Gottsteix, 495, 498. 
Gowers, 319, 446, 574. 
Graefe, 538. 
Graxciier, 625, 771. 
Graxdidier, 65. 
Grawitz, 142. 
Gregor, 133, 404, 439. 
Gregory, 19. 
Griesixger, 341. 
Grisolle, 598. 
Groexow, 92. 
Groxbech, 494. 
Gruber, 498. 
Grutzxer, 543. 
Guelliot, 770. 
Guexiot, 60. 
Guerin, 243, 260. 
Guersaxt, 509, 515, 754. 
Guibert, 515. 
Guxdobin, 155, 157. 

GtJRGEXS, 312. 

Gusserow, 90. 

GUTTMANN, S., 342. 

Gitye, 493, 494. 

Haabermas, 446. 
Haase, 88. 

II ABEL, 202. 

Hack, 494. 
Haddex, 319. 
Hagex-Torx, 240. 
Hagexbach, 248, 582. 
Hahn, 402. 
Hahxel, 181. 
Halbeis, 491. 
Halberstamm, 96. 
Hall, Marshall, 33, 404. 
Halliox t , 545. 
Hammer, 299. 
Hansemaxx, 746, 755. 
Hanszel, 477. 
Hartmanx, 491, 498. 
Hatry, 771. 
Hauchecorne, 239. 
Haudeck, 51. 
Hattg, 494. 
Haupt, 287. 
Hauser, 426, 428. 
Haush alter, 319. 



INDEX OF AUTHORS 



795 



Hayem, 98. 

Hearsox, 15. 

Hecker, 27, 114, 119, 310, 311, 322, 434. 

Hedrich, 19. 

Heermaxx, 490. 

Heim, 19. 

Heine, 553, 558. 

Heixecke, 68. 

Heise, 530. 

Hektoex, 672. 

Helferich, 57. 

Hellexdal, 322. 

Hexke, 519. 

Hexkel, M., 526, 529 

Hexle, 480. 

Hexxig, 74. 

Hexoch, 48, 102, 104, 111, 116, 265, 280, 
284, 293, 295, 302, 317, 320, 333. 335, 
344, 348, 358, 409, 435, 446, 459, 464, 
467, 503, 504, 505, 506, 519, 520, 522, 
527, 537, 589, 771, 773. 

Hexschel, 188. 

Hexschex, 530. 

Hexsel, 776. 

v. Herff, 777. 

Hermax, 520. 

Hervieux, 104, 153. 

Herzog, 82. 

Hessixg, 561. 

Hesslixg, 160. 

Heubxer, 105, 107, 111, 126, 129, 132, 
167, 174, 189, 201, 202, 204, 206, 217, 
218, 219, 220, 226, 227, 241, 249, 273, 
274, 280, 284, 300, 304, 309, 324, 434, 
442, 446, 484, 485, 513, 517, 571, 572, 
579, 580, 582, 583, 584, 711, 771. 

vax t Heukelom, Siegexbeck, 69. 

Heusxer, 567. 

Hewitt, 99. 

Hilbert, 516, 672. 

HlLDEBRAXDT, 19, 20. 

Hippocrates, 763, 769. 
Hirsch, 89, 238, 764. 

HlRSCHBERG, 324. 

Hirschler, 162. 

Hirschsprung. 187, 355. 

Hitzig, 393, 519. 

Hochsixger, 10, 252, 269, 309, 311, 315, 

319, 322, 329, 470, 471, 472, 475, 484, 

485, 764, 765. 
hoedemaker, 58. 
Hoff, 672. 



Hoffa, A., 539. 

Hoffmaxx, 63, 132, 429. 

hoffmeister, 98. 

Hofmeier, 90, 91, 97, 98, 99, 100, 101. 

hoiilfeld, 403. 

Holt, 195. 

holzkxecht, 316. 

Homaxs, 765. 

HOOGEWEG, 27. 
HOPFEXGARTXER, 509. 

Hopmaxx, 487, 494. 
Horsley, 443. 
Huber, 504. 

HUETER, 541. 

Hufelaxd, 32, 769. 

Huguexix, 512, 531. 

Huter, 29, 290. 

Hutixel, 244, 509. 

V. Huttexbrexxer, 68, 459, 463. 

Lllixg, 62. 

IXGERSLEV, 217. 
ISHAM, 771. 

Israel, 707. 

Jaccoud, 509, 771. 

Jacob, 305, 766, 770. 

Jacobi, 406. 

Jacobsthal, 221. 

de Jager, 153, 170, 214, 513. 

v. Jaksch, 259. 

Jalland, 217. 

James, 244. 

Japha, 430, 431, 432. 

Jehle, 20. 

Jetter, 57. 

Jochmaxx, 776. 

JOFFROY, 771. 

Johaxxessex, 192, 229, 238, 239, 671, 

673, 674, 675, 700, 718. 
Johxe, 287. 
Jolly, 350. 
Jorg, 155. 
Joucoxsky, 239. 
Jurasz, 498. 

Jurgexsex, 661, 672, 718. 
Justi, 498. 

Kafemaxx, 488. 
Kalischer, 319, 330, 347. 
Kaltexbach, 49. 
Kamex, 121. 



796 



INDEX OF AUTHORS 



Kamps, 257. 

Kanzleb, 292. 

Kaposi, 710. 

Karciier, 329. 

Karewski, 304, 542, 548. 

Kablinski, 84. 

Kabvonen, 310, 311, 322. 

Kassowitz, 237, 238, 239, 240, 241, 242, 
243, 248, 252, 262, 263, 264, 271, 273, 
279, 280, 281, 395, 396, 398, 399, 406, 
411, 412, 419, 421, 429, 435, 437, 441, 
442, 443, 452, 453. 

Katz, 755. 

Kaufmann, 294, 702. 

Kehrer, 96, 98, 132. 

Keilmann, 81. 

Keller, 78, 133, 206, 208, 209, 240, 335. 

Key, Axel, 518. 

Kiesselbach, 466, 476. 

KlNDERLEN, 20. 

KlRCHGASSER, 429, 455. 

Kirmisson, 41, 545. 

Kissel, 239. 

Klebs, 509, 704, 735. 

Klecinsky, 246. 

Klein-Schweciiten, 240. 

Klemperer, G., 230. 

Kling, 114. 

Klingemann, 402. 

Knappe, 47. 

Knopf, 160, 287. 

Knopfelmacher, 109, 183, 188, 189, 244, 

249, 284. 
Koch, 105, 154, 286, 581, 582. 
Kochel, 16, 288. 
K offer, 31, 32. 

KOHLBRTJGEL, 172. 

Kohts, 457, 460. 
kolaszek, 68. 
Konig, 37, 302, 303. 
Koplik, 503, 506, 507, 631. 
Koppel, 464. 
Koppen, 188. 
Koeber, 31. 
Korner, 488, 492, 494. 
Korowin, 155. 
Kotelmann, 475, 494. 
Kraepelin, 432. 
Krafft-Ebing, 343. 
Krahmer, 27. 
Kraus, 319, 586, 723. 
Krause, 286, 292, 303, 443. 



Krausiiaar, 426. 

Kriecer, 157. 

Kroner, 675. 

Kruckenberg, 85, 561, 565. 

Kruse, 164. 

Krusen, 21. 

Ku-Xdratii, 45, 113, 114, 115, 117. 

Kunkel, 460. 

Kussmaul, 337, 339, 343, 427, 459, 539, 

754. 
Kusmin, 78. 

Kustner, 44, 49, 50, 54, 55, 56, 59, 68. 
Kuttner, 259, 481. 

Laache, 577. 

Labbe, 246. 

Laborde, 34. 

Laennec, 285. 

Laghi, 769. 

Lah, 34. 

Lambl, 153. 

Landau, 115, 117. 

Landolt, 530. 

v. Lange, 39, 206, 239, 240, 404, 435, 494, 

498. 
Langer, 109. 
Lannelongue, 304. 
Lauth, 33. 
Laveran, 765, 773. 
Lazarus, 337. 
Lebert, 10. 

Le Gendre, 79, 153, 533. 
Legg, 104. 
Lehmann, 16, 288. 
Leichtenstern, 764, 765, 766, 772. 
Le Lorier, 463. 
Leniiartz, S., 672. 
Lennander, 193. 
Lenz, 242. 
Leopold, 90. 
Le Pileur, 324. 
Lesage, 164, 165. 
v. Leube, 305, 526, 529, 577. 
v. Leyden, 509, 513, 518, 523, 530. 

LlCnENSTEDT, 154. 

Ltchtenstein, 265, 344. 

LlEBERMEISTER, 287. 
LlNSER, 57. 

Ltppe, 286. 

Little, 553, 554, 556, 558. 

LOBKER, 187. 
LOEFLAND, 195. 



INDEX OF AUTHORS 



797 



Loffler, 735, 737. 
Loiians, 403. 
Lombard, 765, 766. 

LONGUET, 773. 

Loomis, 516. 

Loos, 263, 418, 426, 429, 432, 441. 

Lorenz, 542, 554, 567. 

Louis, 153. 

Love, 230. 

Lubarsch, 289. 

Lublinski, 477, 488. 

Ludwig, 47, 162. 

Ludwig, C, 396. 

Lugol, 287. 

Luhe, 764. 

Luigi, 464. 

Lukjanow, 171. 

Lungwitz, 287. 

Lunin, 128. 

Lutii, 330. 

Mackenzie, 491. 

Malkoff, 579. 

Mallory, 672. 

Malvoz, 287. 

Manicatide, 455. 

Manigault, 746. 

Mann, 427, 428. 

Mann, Dixon, 711. 

Maragliano, 307, 579. 

Marchand, 21. 

Marfan, 161, 169, 239, 246, 516, 

532, 773. 
Marie, Pierre, 446. 
Martens, 516. 
Martin, 15, 30, 77. 
Mascagni, 480. 
Massolongho, 322, 324. 
Masur, 289. 
Matthewson, 312. 
de Mattos, 214. 
Mauriceatj, 61. 
May, 785. 
Mayer-Huni, 777. 
Mayr, 153, 462. 
Meinert, 165. 
Meissner, 84, 160. 
Mekus, 104. 
Mendel, 249, 284. 
Mendelsohn, 516. 
Menko, 576. 
Mercurialis, H., 344. 



526, 



Messerer, 545. 

Mkssmer, 62. 

v. Metteniieimer, 249, 284, 773. 

Mey, 239, 244. 

Meyer, E., 202. 

Meyer, H., 580, 582, 583. 

Meyer, William, 486, 487, 488, 491, 493, 

494, 507. 
Meynert, 578. 
Meynet, 19. 
Michaelis, 765. 
Michel, 476. 
Micholet, 408. 
Mihalkovtcz, 476. 
Miller, 138, 139. 
Minkowski, 527. 
Mirallie, 545. 
Mircoli, 248. 
Miwa, 247. 
Mobius, 350. 
Moizard, 725. 

MOLDENHAUER, 105. 
MOLLER, 217. 

Moncorvo, 238, 239. 

Money, 539. 

Monti, 15, 132, 238, 241, 246, 251, 259, 

280, 332, 333, 334, 467, 538, 672, 770. 
Moreau, 446. 
Morf, 464. 
Mori, 242. 
Moro, 163. 
Moser, 409. 

Most, 480, 481, 501, 502. 
moussarrat, 545. 
Moussous, 393, 394, 404, 405, 408. 
Mracek, 66, 327. 
Muller, 259, 578. 
Muller, E., 455. 
Muller, Leopold, 464. 
Muller, P., 83. 
Muller, W., 303. 
Mygind, 343. 

Naegeli, 221. 

Naef, 554. 

Naumann, 769. 

Naitnyn, 100, 578. 

Nauwerck, 221, 578. 

Navratil, 481. 

Neisser, 85, 88. 

Netter, 21, 229, 509, 513, 514, 530, 

Neuhaus, 19. 



798 



INDEX OF AUTHORS 



Neumann, 84, 97, 98, 216, 241, 265, 280, 

295, 464, 501, 503. 
Neurath, 256, 407. 
Neuretter, 295. 
Nicloux, 402. 
Nicoladoni, 563. 

NlEBERDING, 115. 

Niemeyer, 409. 
Nocard, 287. 
v. Noorden, 730. 
Nothnagel, 168, 391. 

Odile, 15. 
O'Dwyer, 754. 
Oedmanson, 319, 322. 
Ohlfeld, 69. 

OlILMULLER, 204. 

Olivier, 574. 

Ollier, 563. 

Olshausen, 27, 28, 29, 43, 44, 47, 48, 104. 

Oppenheim, 574, 576. 

Oppenheimer, 249, 267, 319, 357, 503. 

Ortii, 84, 97, 302. 

Osler, 446, 556. 

d'Outrepont, 27. 

Pailhas, 771. 

Paltauf, 444. 

Paneth, 393. 

Parrot, 112, 196, 231, 267, 317. 

Passini, 15. 

Pasteur, 154. 

Pavoine, 515. 

Pavone, 241. 

Pawlow, 360. 

Peaudecerf, 78. 

Peiper, 474. 

Penzoldt, 767. 

Permewan, 493. 

Pernice, 32, 33, 68, 69. 

Perret, 408. 

Peters, 318, 428. 

Peters, R., 455. 

Pfaundler, 155, 166, 187, 208, 209, 247, 275. 

Pfeiffer, 181, 483, 484, 485, 639, 776. 

Phobus-Blackley, 462. 

Pianese, 579. 

Pick, 586. 

Picot, 516. 

Pierce, 771. 

Piffl, 301. 

PlNELES, 264. 



Pjotrowski, 91. 

PlZZINI, 516. 

Plant, E., 161. 
Plenk, 519. 
Pluder- Fischer, 495. 
polaillon, 59. 
Politzer, 155, 498, 527. 

POLYA, 481. 

Pommer, 237, 271, 272, 273. 
POMOBSKI, 114. 
PONFICK, 290. 

Popow, 124. 
Porak, 62, 78, 96, 97. 
Porier, 481. 
Pospischill, 462. 
Potier, 19. 
Pott, 329, 530, 533. 
pourtual, 19. 
Pratolongo, 771. 
Prausnitz, 160. 
Prautois, 769. 
Preobrasciiensky, 443. 
Prevost, 539. 
Preyer, 337, 341. 
Prichard, 578. 
Prudden, 289. 
Putnam, 402. 

Quin, 515. 

Quincke, 100, 510, 518, 528, 530, 538. 

Quisling, 240, 241. 

Rabert, 581, 582. 

Rahlmann, 522. 

v. Ranke, 129, 535, 538, 665, 758. 

Ranvier, 766. 

Rasori, 611. 

Rasthorn, 30. 

Rau, 154. 

Rauchfuss, 10, 115. 

Raudnitz, 435, 437, 452. 

v. Recklinghausen, 221, 272. 

Reclus, 548. 

Reiier, 19, 20. 

Reiin, 37, 226, 239, 267, 439. 

Reich, 29. 

Reicke, 512. 

Reincke, 670. 

Rembold, 113. 

Renon, 16. 

de Renzi, 287. 

Rethi, 495. 



INDEX OF AUTHORS 



799 



Retzius, 518. 

Reubold, 631. 

Reuter, 317. 

Rey, 240, 281, 282, 461, 494. 

Reyling, 92. 

Rhinecker, 631. 

RlCHARDIERE, 558. 

Riedel, 540, 541. 

RlEFEL, 551. 

Riehl, 332. 

RlGBY, 104. 

Rilliet, 114, 260, 295, 462, 509, 515, 516, 
519, 520, 532, 765, 770. 

RlXDFLEISCH, 16. 
RlNGBERG, 772. 

V. Ritter, 108, 153, 241, 243, 265, 267. 

V. RlTTERSHAIN, 237. 

Rizet, 770. 

Robin, 82. 

Roger, 539, 582. 

Roger, Saint- Ange, 410. 

Rohrer, 520. 

rokitansky, 31. 

Roloff, 247, 288. 

Romberg, 343, 435. 

Rommel, 15. 

Roon, 269. 

Rosemann, 402. 

Rosen, 313. 

Roser, 5. 

Rossi, 164. 

Rotch, 195. 

Roth, 494. 

Rothschild, 131. 

Roux, 735, 737. 

Rudel, 246. 

Ruffini, 578. 

Ruge, C, 98. 

Runge, 31, 41, 78, 84, 90, 119. 

Rupprecht, 553, 554. 

Rusz, 515. 

Ruter, 18. 

Sachs, 558, 579. 
Saenger, 509. 
Sainton, 545. 
Salzwedel, 81. 
Sandner, 121. 
Sandstrom, 445. 
Sanger, 358. 
Sanne, 770. 
Sappey, 480. 



de Sauvages, 344. 
Sciiafer, 509. 
sciiarlach, 672. 
Schauta, 34. 
sche1nmann, 464.. 
Schick, 266. 
schierbeck, 161. 
Schiff, 259, 333. 

SCHILD, 124. 

Schilling, 516, 538, 586. 
Schlagenhaufer, 464. 

SCHLEGDENDAHL, 292. 
SCHLESINGER, H., 432. 
SCHLIEP, 79. 

Schlossmann, 162, 322, 415. 
Schmaltz, 494. 
Schmidt, 110, 167, 168, 405. 
Schmidt, N., 499. 

SCHMIDT-RIMPLER, 92. 

Schmitz, 503, 506. 
Schmorl, 16, 221, 288. 

SCHNUCKMANN, 488. 
SCHOEDEL, 221. 
SCHOLL, 161. 
SCHONLEIN, 764. 

schrader, 79, 80. 

Schroeder, 27, 28, 29, 34, 40, 45. 

Schucktng, 62. 

Schuller, 303, 430. 

Schulthess, 554, 555. 

Schultze, 518, 557. 

Schultze, F., 58. 

Schulze, B., 24, 26, 27, 28, 29, 31, 32, 46, 

47, 69, 100. 
Schuppel, 311, 321. 
ScHtiTZ, 84, 327, 498. 

SCHUTZE, 47. 

schwabach, 331. 
Schwalbe, 272, 523. 

SCHWALBE, J., 529. 

Schwartz, 27, 551. 

Schwarz, 241, 242. 

Schwenninger, 286. 

See, 574, 578, 582. 

Seelig, 162. 

Seeligmuller, 48, 516, 520, 542, 543, 

547, 548, 549, 552. 
Seeman, 246. 
Seibert, 723. 
Seitz, 239, 241, 295. 
Seitz, J., 618. 
Semon, 443, 488, 494. 



800 



INDEX OF AUTHORS 



Senn, 515. 
Sennebt, G70. 
Shiga, lt'»4. 
Shoemaker, 50, GO. 
Shukowsky, 240. 
Sidlo, 598. 

SlEDAMGROTZKY, 305. 
SlEFERT, 332. 

Siegert, 189, 245, 247, 269, 275, 276, 301. 
SlLBEEMANN, 98, 99, 101, 114, 117, 782. 
SlLEX, 324. 
SlMMONDS, 20. 

Simon, 459, 579, 769. 
Simpson, F. T., 619. 



Slawyk, 6; 



679. 



Snellen, 494. 

Snow, 238. 

Sokoloff, 503. 

Soltmann, 110, 112, 215, 383, 386, 390, 
392, 393, 398, 407, 409, 410, 411, 412, 
467, 468, 571, 573, 575, 578, 579, 580, 
584, 585, 587, 765, 767, 773. 

Somma, 538. 

Sommerfeld, 672. 

sonnenburg, 566. 

Sorensen, 672, 675, 702, 715. ♦ 

Soxhlet, 133, 165, 246. 

Spalteholz, 679. 

Spengler, 307. 

Sperling, Max, 51. 

Spiegelberg, 40, 114, 117. 

Spietschka, 242, 243. 

Spillmann, 237, 242, 247, 249, 274. 

Spirig, 464. 

Spitzmuller, 467. 

Stadelmann, 99. 

Stahr, 480. 

Stamm, 189, 437, 464. 

v. Starck, 129, 226, 259, 464. 

Steffen, 515, 516, 519, 591, 599, 730. 

Stegmann, 236. 

Steiner, 153, 295, 591, 765, 769. 

Steinheim, 423. 

Steinitz, 208. 

Steinthal, 337. 

Sterling, 248. 

Stern, 187. 

Stoerk, 464, 470, 471, 476, 498. 

Stolper, 59, 60. 

Stoltzner. 236, 237, 238, 239, 246, 247, 
248, 249, 254, 260, 264, 266, 267, 268, 
269, 271, 272, 273, 275, 281, 284. 



Stoos, 506. 

Strauss, 189, 289, 708, 728. 

Strelitz, 121. 

Stboebe, 289. 

STROH MAYER, 566. 

Strubing, 468. 

v. Stbumpell, 409, 539, 554, 558, 767. 

VAN SWIETEN, 153. 

Swoboda, 475. 
Sydenham, 571, 670. 
Sylvester, 33, 34. 

Tallon, 771. 

Tappeiner, 286. 

Tarnier, 15, 64. 

Tauffer, 74, 91. 

Temoin, 503, 504. 

Terrier, 310. 

Teschier, 611. 

Thiemich, 208, 263, 265, 350, 366, 404, 

408, 416, 417, 426, 427, 428, 430, 431, 

432, 434, 439, 453, 455. 
Thiry, 319, 330. 
Thomas, 577, 614, 702. 
Thomson, 183, 187. 
Thorburn, 60. 
Thost, 482. 

TlLLMANNS, 69. 

Tipe, 170. 
Tissier, 155. 
Todd, 574. 

TOLANO, 15. 
Tonnele, 421, 515. 
DE LA TOURETTE, 312. 
TOYNBEE, 771. 

Traube, 519. 

Trautmann, 494. 

Travel, 770. 

Treitel, 464. 

Trousseau, 34, 153, 314, 423, 522, 524, 

653, 676, 754. 
Tschistowitsch, 242. 

Uffelmann, 206. 
Uffreduzzi, 509. 
Unna, 332. 
Unruh, 241, 243. 
Unverricht, 387, 443. 

Valleix, 153. 
Varnier, 79. 
Vassale, 445. 



INDEX OF AUTHORS 



801 



Vaughn, 161. 

Veit, 257. 

Veit, G.. 27. 

Veit, O,, 114. 

Verxeuil. 516. 

Vevebka, 91. 

Vidal, 105. 

Vierordt, 246. 248, 254, 255, 256, 259, 

261, 275, 276, 282, 337. 
Vigier, 132. 
Villar, 68. 

VlLLEMIX, 286. 

Violet, 62, 98. 

Virchow, 98, 237, 242, 271, 272, 285, 290, 

523, 537, 557, 755. 
Vogel, 47, 60, 519, 520, 773. 
Voigt, 770. 
Voit, 247. 
v. Volkmaxx, 27, 303, 540, 541. 547, 549. 

VOLTMER, 15. 
VOLTOLIXI, 4S6. 

votteler, 519. 
Vulpiax, 539. 
Vulpius, 564. 

YVachsmuth, 248. 
v. Wagner, 428. 
Wallach. 240. 
Walls, 506. 
Warthix, 85. 

Wassermaxx, 299, 579, 583. 
Weaver, 619. 
Weber, 31, 99, 464. 
Wedexsky, 247. 
Wegxer, 310. 
Wegscheider, 155. 
Weichselbaum, 509, 513. 
Weigert, 69, 295, 677. 



519. 



'3, 153, 162, 335, 409, 



Weinbuch, 171. 

Weiss, 664. 

Werner, 541. 

West, 99, 167, 459, 574, 578. 

Westphal, 387, 398, 411, 427, 579, 583. 

Weyl, 307. 

Whigham, 106. 

White, 765. 

Whytt, Robebt, 515, 517. 

Wicke, 571. 

WlCKHAM, 104. 
WlDAL, 19. 

V. WlDEBHOFEB, 
716. 

Widowitz, 259. 

v. Wixckel, 15, 104, 105, 116, 120, 121. 

WlXTEB, 31. 

Wissmaxx, 289. 

WlTTHAUEB, 468. 

Wittkowski, 522, 570. 

Wolff, 17, 57, 84. 

Wollexbebg, 571, 576, 580, 581, 582. 

Wyssokowitsch, 289. 

Yebsix, 735, 737. 

Zadock, 505. 

Zaxdeb, 246. 

Zappebt, 318, 409, 455, 456. 

Zechmeisteb, 105. 

Zenker, 142. 

ZlEGLEB, 221, 222. 

Ziem, 464, 492, 494. 

Ziemssex, 33, 571, 574, 581. 

ZlEBMANN, 62. 

Zossexsteix, 771. 

ZUPPIXGEB, 118. 

Zweifel, 90, 91, 155, 246, 247. 



INDEX OF SUBJECTS 



Abdomen, examination of. in disease of 

pylorus, 185. 
Abdominal organs, injury to, during la- 
bor, 50. 
Ablactation diarrhea. 165. 
Abortion due to syphilis, 300. 
Abortive pneumonia, 597. 
Abscess, in diphtheria, 747. 

of lung, in pneumonia, 599. 

retropharyngeal, 502. 
Acardiacus. 8. 
Acephalus, 8. 
Acid fermentation, due to saprophytic 

bacteria, 140. 
Acne in scrofula, 291. 
Acormus, 8. 
Acrania, 1. 

Acute digestive disturbances. 153. 
Acute fatty degeneration of the new-born, 

118. 
Adenoid pbaryngeal vegetations. 4S4. 
Adenoid tissue of nasopharynx, 479. 
Adenoid vegetations, 486. 

chorea and, 494. 

diagnosis of, 495. 

differential diagnosis of, 496. 

frequency of, 488. 

history of, 4S6. 

in scrofula, 291. 

prognosis of, 497. 

relapses in, 499. 

symptoms of, 489. 

treatment of, 497. 
subsequent, 499. 
Adenomata, umbilical, 68. 
Adrenals, hematoma of, 50. 

syphilis of, 324. 
Ahlfeld's method in care of navel, 77. 
Albumin water in diarrhea, 169. 



Albuminuria in mumps, 771. 

intermittent, in scarlatinal nephritis. 711. 
Alcohol, as a food for infants, 137. 

in care of navel, 70. 
Alcoholic intoxication, cause of convul- 
sions, 402. 
Alimentary damage, cause of hyperirrita- 

bility spasms, 431. 
Alimentary dyspepsia, 159. 
Alkali, addition of, to milk. 129. 
Allaitement mixte, 127. 
Allenbury's infant food, 214. 
Alopecia in syphilis, 327. 
Amaurosis in tuberculous meningitis, 523. 
Amblyopia in tuberculous meningitis. 523. 
Amniotic bands, 38. 
Amorphus, 8. 
Anal eczema, 142. 
Anal erythema, 142. 
Anemia in syphilis, 324. 

pseudoleucemia infantum, 324. 
Anencephalus, 1. 
Anesthesia in adenoids, 49S. 
Angina pultacea in scrofula, 291. 
Angina pustacea in scrofula, 291. 
Anorexia in adenoids, 494. 
Antiperistaltic wave in pyloric stenosis, 

186. 
Antitoxin in diphtheria, 756. 
Anus, atresia congenita of, 5. 

malformations of, 5. 

praeternaturalis, 12. 

urethralis, 6. 

vesicalis, 6. 
Aortic stenosis, congenital, 8. 
Aphasia, 344. 

after accumulation of feces, 344. 

after nematodes, 344. 

due to oxvuris vermicularis. 344. 



803 



804 



INDEX OF SUBJECTS 



Aphasia, dyspeptica, 344. 

from overloading of stomach, 344. 
helminthica, 344. 
voluntaria, 342. 
Aphonia in diphtheria, 751. 

syphilis, 31G. 
Aphthous stomatitis, 145. 

in measles, 647. 
Apnea, expiratory, 419. 
in infancy, 334. 
in whooping cough, 779. 
Apoplexy, cerebral, in whooping cough, 

785. 
Apparatus, circulatory, defects of, 8. 

urinary, defects of, 6. 
Appendicitis in scarlet fever, 692. 
Aprosexia nasalis, 493. 
Arm, paralysis of, 57. 
Arteritis, 72. 

Arthritic affections in measles, 654. 
Arthritic suppuration of the new-born, 72. 
Arthrogryposis, 409. 

Articulation, congenital weakness of ap- 
paratus of, 343. 
Artificially fed infants, chronic intesti- 
nal disturbance of, 196. 
Asphyxia, local, 359. 
of the new-born, 22. 
cause of, 23. 

convulsions caused by, 407. 
degrees of, 35. 
diagnosis of, 23. 
pathology of, 22. 
prognosis of, 26. 
prophylaxis of, 26. 
pulse in, 23, 25. 
symptoms of, 23. 
treatment of, 26. 

contractions of tongue in, 34. 
faradization of phrenic nerve in, 32. 
galvanization in, 34. 
Lah's method of, 34. 
Marshall Hall's method of, 33. 
Schroeder's method of, 34. 
Schulze's method of, 30. 
Sylvester's method of, 33. 
summary of, 35. 
post partum, 36. 
etiology of, 36. 
prognosis of, 37. 
symptoms of, 36. 
treatment of, 37. 



Astasia-abasia, 365. 
Asthenopia, nervous, 358. 
Asthma, bronchial, 359. 
prophylaxis of, 372. 
in adenoids, 494. 
thymicum, 445. 
Asthmatic attacks in heart disease, 9. 
Athetosis, 558. 

treatment of, 568. 
Athrepsia, 196. 
Atrophy, genuine, 198. 

acid intoxication in, 207. 
acidosis in, 207. 
alimentary hyperacidity in, 209. 
cause of, 200. 

fat-feeding acidosis in, 209. 
metabolism in, 206. 
pathology of, 202. 
symptoms of, 199. 
termination of, 200. 
treatment of, 210. 
astringents in, 215. 
drugs in, 215. 
enteroclysis in, 216. 
weight curves in, 201. 
in infantile tuberculosis, 294. 
of breast-fed children, 179. 
diagnosis of, 180. 
etiology of, 179. 
simple, treatment of, 210. 
Autointoxication, gastrointestinal, 403. 

cause of hyperirritability spasms, 430. 
Automatic movements, 355. 

Bacillosis, 165. 

Bacillus, diphtheria, 735. 

maximus buccalis, 139. 

pseudo-diphtheria, 735. 
Bacteria of decomposition in oral cavity, 

148. 
Bacteriology of acute digestive disease, 154. 

rhinitis, 457. 

scarlet fever, 672. 
Barlow's disease. See Infantile Scurvy. 
Bartholinitis in mumps, 770. 
Basedow's disease, 376. 
Basilar meningitis due to syphilis, 319. 
Bathing of infants, 80. 
Bednar's aphthae, 147. 

etiology of, 147. 

symptoms of, 147. 

treatment of, 152. 



INDEX OF SUBJECTS 



805 



Bellocq's tube in epistaxis, 477. 

Belly, scaphoid, in tuberculous meningitis, 

520. 
Biedert's cream mixture in pyloric steno- 
sis, 189. 
Biliary passages, inflammation of, in 

syphilis, 321. 
Birth, trauma during, 37. 
Blaschko's bandage in syphilis, 332. 
Blennorrhea, 71. 

neonatorum, 87. 
Blepharospasm in scrofula, 291. 
Blindness due to gonorrheal inflammation 
of eyes, 89. 
whooping cough, 784. 
Blood typhoid, 20. 
Bocknase, 472. 
Bone, nasal, fracture of, during labor, 48. 

occipital, injuries to, 43. 
Bones, cranial, injuries to, 42. 
prognosis of, 42. 
treatment of, 42. 
fracture of, in infantile scurvy, 219. 
syphilis of, 316. 
tuberculosis of, 302. 
Boring of nose, 474. 

Bottle-fed infants, chronic digestive dis- 
turbances of, 196. 
Brain, convulsions and organic affections 
of, 448. 
disease of, in the new-born, 72. 
focal disease of, in meningitis, 524. 
hypertrophy of, in rickets, 266. 
organic affections of, and convulsions, 

differential diagnosis of, 448. 
rapid growth of, in convulsions, 385. 
Breast-fed children, atrophy of, 179. 
Breast milk, cow's milk, and differences 
between, 154. 
substitute for, 128. 
Bromoform in Avhooping cough, 788. 
Bronchi, disease of, from adenoids, 491. 
Bronchial asthma, 359. 
Bronchiectasis in whooping cough, 781. 
Bronchiolitis in measles, 649. 
Bronchitis, capillary, acute, in measles, 
648. 
clinical picture of, 650. 
course of, 649. 
in measles, 641. 
symptoms of, 649. 
emetics in, 667. 



Bronchitis, in measles, 629. 
scarlet fever, 712. 
scrofula, 291. 
whooping cough, 781. 
putrid, 141. 
Broncho-pneumonia, 593. 
chronic, 600. 
course of, 600. 
in diphtheria, 747. 
in whooping cough, 781. 

measles and, 601. 
prognosis of, 600. 
symptoms of, 593. 
treatment of, 607. 
Brunnengraber's crystallized malt extract, 

214. 
Bubo, concentual, 292. 
Buccal mucous membrane, lymph supply 

of, 481. 
Buhl's disease, 65, 118. 

differential diagnosis of, 119. 
etiology of, 119. 
pathology of, 118. 
prognosis of, 120. 
symptoms of, 119. 
treatment of, 120. 
Buttermilk, 214. 

Canal, intestinal, constriction of, 6. 
Cancrum oris, 653, 665. 
Caput obstipum, 50, 544. 
Cardia, constriction of, 6. 

stenosis of, 6. 
diagnosis of, 6. 
prognosis of, 6. 
Cardiac affections in measles, 654. 
Cardiac dyspnea in nephritis, 709. 
Cardiac hypertrophy in rickets, 260. 
Cardiac syncope in congenital heart dis- 
ease, 9. 
Carotids, compression of, in convulsions, 

451. 
Casein, action of, 163. 
Cataleptic phenomena in rickets, 437. 
Cataract, anterior capsular, 87. 
Catarrh, alimentary, 167. 

dyspeptic, 167. 

inflammatory, 167. 

silver, 89, 90. 

simple, 167. 

suffocative, in measles, 649. 
Catarrhal stomatitis, 139. 



806 



INDEX OF SUBJECTS 



Catastrophes, 201. 
in measles, 638. 
Cavity, thoracic, incomplete closure of, 7. 
Cephalhematoma, 39. 
diagnosis of, 41. 
etiology of, 39. 
symptoms of, 40. 
treatment of, 41. 
Cerebral cortex in convulsions, 391. 
Cerebral hemiplegia, 558. 
diagnosis of. 559. 
etiology of, 558. 
symptoms of, 559. 
treatment of, 509. 
Cerebral paralysis, infantile, 539, 553. 
prognosis of, 560. 
treatment of, 500. 
Cerebral vomiting, 300. 
Cerebrospinal meningitis, 513. 
Cervical lymphatics, enlargement of, in 

rubella, 613. 
Charcot's etat de mal choreique, 585. 
Cheeks, skin of, lymph supply of, 481. 
Cheyne-Stokes respiration in tuberculous 

meningitis, 522. 
Child, normal, nutrition of, 124. 
Chicken breast, 254. 
Children, feeding of, 122. 
Chloroform inhalations in convulsions, 

451. 
Chorea, 375. 

acute articular rheumatism and, 576, 

582. 
adenoid vegetations and, 494. 
anglorum, 571. 
cordis, 573. 
germanorum, 571. 
heart disease and, 577. 
imitatoria, 582. 
laryngea, 573. 
magna, 570, 571. 
minor, 570. 

abortive types of, 576. 
complications of, 576. 
course of, 576. 
diagnosis of, 577. 
etiology of, 579. 
age in, 579. 

climate and season in, 580. 
heredity in, 581. 
sex in, 580. 
special predisposing causes in, 581. 



Chorea, minor, history of, 570. 

pathogenesis of, 584. 

pathology of, 577. 

prodromes in, 572. 

prognosis of, 584. 

relapse in, 570. 

sequels of, 577. 

symptoms of, 571. 

synonyms of, 570. 

treatment of, 585. 
mollis, 574. 
nocturna, 574. 
paralytica, 574. 
Cholera, Asiatic, 163. 

infantum, 173. 
Chondrodystroph i a, 24 1 . 
Choroid tubercles, 523. 
Choroiditis in syphilis, 319. 
Choroidoretinitis, 323. 
Chvostek's sign in rickets, 262. 

tetany, 426. 
Chyme infection, 162, 163. 
Circulation, placental, 22, 23. 
Circulatory apparatus, defects of, 8. 
Cirrhosis, biliary, due to syphilis, 321. 
of liver, syphilitic, differentiation of, 
from congenital agenesia, 322. 
Clavicle, fracture of, 52. 

prognosis of, 53. 

symptoms of, 53. 

treatment of, 53. 
Claw-hand in spinal paralysis, 547. 
Cleft palate, 4. 
Club-foot, 12, 551. 
Club-hand, 12. 

Coagulation necrosis in scarlet fever, 677. 
Colic, gastric, 359. 
Colles's law, 334. 
Colostrum, 94. 

milk, 177. 
Coma in tuberculous meningitis, 524. 
Condylomata in infantile syphilis, 316. 
Congenital aortic stenosis, 8. 
Congenital cystic kidney, 6. 
Congenital dislocation of femur, 12. 
Congenital enlargement of pharyngeal ton- 
sil, 488. 
Congenital hydrocephalus, 531. 
associated with syphilis, 318. 
Congenital pulmonary stenosis, 8. 
Congenital spastic rigidity, 553. 
Congenital rickets, 241. 



INDEX OF SUBJECTS 



807 



Congenital vitia cordis, 8.- 
Congenital weakness of apparatus of ar- 
ticulation, 343. 
Congestion pulmonaire aigue, 597. 
Conjunctiva, diphtheria of, 751. 
Conjunctivitis, gonorrheal, 87. 
Constipation, a cause of convulsions, 
405. 
a factor of speech disturbances, 343. 
apparent, 125. 
chronic, 191. 

symptoms of, 191. 
treatment of, 193. 
habit, 366. 
habitual, 191. 

in tuberculous meningitis, 520. 
Constitutional diseases, 96. 
Constriction of pylorus, 183. 
Contractures in spinal paralysis. 540. 

tuberculous meningitis, 523. 
Convulsions, 348, 382. 

affections of brain, organic, and, 448. 
diagnosis of, 445. 
etiology of, 348, 384. 
heredity in, 386. 
individual predisposition in, 386. 
mechanical irritation in, 387. 
psychical hypersensitiveness in, 386. 
psychical state in, 390. 
rapid growth of brain in, 385. 
respiratory influences in, 388. 
rickets in, 388. 
essential, 382. 
febrile, 400, 401. 
functional, 383. 
hyperirritability. 416. 

symptoms of, 417. 
idiopathic, 382. 
in infantile scurvy, 220. 
measles, 653. 
pneumonia, 592. 
rickets, 262. 
scarlet fever, 680. 
tuberculous meningitis, 523. 
whooping cough, 781. 
occasional, 399. 
etiology of, 401. 

alcoholic intoxication in. 402. 
asphyxia in, 407. 
autointoxication in, 401. 
congenital heart disease in, 406. 
cutaneous irritation in, 406. 



Convulsions, occasional, etiology of, denti- 
tion in, 406. 
endogenous causes in, 403. 
exogenous poisoning in, 401. 
fever in, 403. 
gastrointestinal autointoxication in, 

403. 
helminthiasis in, 405. 
intestinal disease in, 401. 
lead poisoning in, 402. 
opium in, 402. 
pertussis in, 406. 
physical factors in. 406. 
reflex causes in. 405. 
santonin in, 402. 
worms in. 404. 
prognosis of, 408. 
organic, 383. 
overirritability. 383. 
pathogenesis of, 384. 
pathology of, 454. 
prognosis of, 449. 
prophylaxis of, 450. 
simple, 390. 
symptomatic, 382. 
treatment of, 450. 

carotids in, compression of, 451. 
chloroform inhalations in, 451. 
cutaneous irritants in, 451. 
hydrotherapy in, 451. 
varieties of, 399. 
venesection in, 451. 
Cord, umbilical, diseases of, 62. 
Cortical irritation and respiratory dam- 
age, 443. 
Coryza, acute, 457. See Acute Rhinitis, 
in measles, 629. 
syphilitica, 313, 469. 
Cough, due to reflex irritation of mucous 
membrane of nose, 777. 
during sleep, 354. 
hysterical, 490. 
in measles, 630. 
Cow's milk, 128. 
dilution of, 131. 

estimated quantity of, for a meal, 130. 
manner of preparation of, 128. 
Coxa vara in rickets, 257. 
Coxitis, tuberculous, 304. 
Cranial bones, injuries to, 42. 
Craniotabes, 251. 

spasm of glottis and, 442. 



808 



INDEX OF SUBJECTS 



Cranium, rachitic, 253. 
Cranium natiforme, 268. 
Credo's method in gonorrheal inflamma- 
tion of eyes, 88, 89. 
Credo's ointment in mastitis, 94. 
Cris hydrencephaliques, 521. 
Crisis in pneumonia, 595. 
Croup, diphtheritic, 731. 

false, 359. 

in measles, 648. 

pseudo-, 749. 

in adenoids, 491. 
Cryoscopy in scarlatinal nephritis, 706. 
Cutaneous affections in mumps, 771. 
Cutaneous diphtheria, 751. 
Cutaneous irritants in convulsions, 451. 
Cyanosis, congenital, 9. 

Dance disease, 570. 
Dauermilch, 129. 
Dead speech in adenoids, 493. 
Deaf mutism, 34.1. 

physiologic, of new-born, 337. 
Deafness, in syphilis, 331. 

voluntary, 341. 
Death, sudden, in syphilis, 324. 
Debility, general, 13. 

specific, 325. 
Defective development of the new-born, 1. 
Defects of kidney, 6. 
Deficient involution of the fontanelles in 

rickets, 251. 
Deformities of the nose in syphilis, 472. 
Degeneration, reactions of, in spinal pa- 
ralysis, 540. 
Deglutition in chorea, 573. 
Deglutition pneumonia, 602. 
Delirium in measles, 652. 
Delpech's antagonistic theory of muscles, 

541. 
Dentition, convulsions and, 406. 

in hydrocephalus, 534. 
Dentition diarrhea, 165. 
Depression in speech disturbance, 343. 
Dermatitis exfoliativa, 108. 

pathology of, 108. 

prognosis of, 108. 

symptoms of, 108. 

treatment of, 108. 
Dermatol in care of the navel, 79. 
Descensus testiculorum, 13. 
Diaphragm, congenital cleft of, 8. 



Diarrhea due to dentition, 165. 
mechanical irritation, 165. 
protozoa, 165. 
thermic influences, 165. 
weaning, 165. 
epidemic, 104. 
in diphtheria, 747. 
infantile scurvy, 234. 
measles, 651. 
scarlet fever, 713. 
infectious, 166. 
septic, 164. 
symptomatic, 164. 
toxic, 165. 
Diazo-reaction in measles, 634. 

in rubella, 621. 
Diet for the second year, 135. 

third year, 137. 
Digestive diseases, acute, 153. 
bacteriology of, 154. 
due to helminths, 165. 
etiology of, 158. 

anatomical and functional insuffi- 
ciency of digestive apparatus in, 
159. 
bacteria in, 160. 
food in, 159. 

lactic-acid fermentation in, 160. 
groups of, 158. 
history of, 153. 
physiologic aspects of, 156. 
physiology in, 154. 
prophylaxis of, 173. 
symptoms of, 167. 
catarrh in, 167. 
dyspepsia in, 167. 
inflammation in, 167. 
treatment of, 168. 

albumin water in, 169. 

buttermilk in, 170. 

calomel in, 169. 

care and support of function in, 

170. 
castor oil in, 169. 

cleanliness of oral cavity in, 169. 
cultures of bacterium lactis aeroge- 

nes in, 170. 
drugs in, 170. 
enemata of starch in, 170. 
irrigation of intestine in, 169. 

of stomach in, 169. 
minimal diet in, 168. 



INDEX OF SUBJECTS 



809 



Digestive diseases, acute, treatment of, 
relief of abnormal decomposition 
in, 169. 
removal of harmful masses in the 

intestine in, 169. 
substitutes for milk in, 170. 
chronic, of breast-fed children, 176. 
symptoms of, 176. 
treatment of, diet in, 211. 
Digestive disturbances, chronic, of in- 
fancy, 176. 
treatment of, 209. 
Digestive tract, malformations of, 4. 

septic infection from, 83. 
Digital examination in adenoids, 496. 
Dilatio et hypertrophia coli congenita, 

192. 
Diphtheria, 731. 
carriers of, 753. 
clinical course of, 732. 
complications of, 747. 
cutaneous, 751. 
definition of, 731. 
diagnosis of, 752. 
etiology of, 733. 
age in, 733. 
bacillus of, 735. 
contagion in, 734. 
geographical distribution in, 733. 
predisposition in, 734. 
season in, 733. 
history of, 731. 
immunization in, 759. 
larval, 748. 
laryngeal, 748. 
latent, 748. 
measles and, 751. 
nasal, 747. 
pathology of, 736, 740. 

toxin of, 737. 
prognosis of, 752. 
rhinitis in, 463. 
scarlatina and, 751. 
statistics in, v 760. 
symptoms of, 737. 
anesthesia in, 747. 
cardiac phenomena in, 742. 
constitutional, 739. 
kidney in, 744. 
paralysis in, 745. 
early, 746. 
late, 746. 



Diphtheria, symptoms of, paresthesia in, 
747/ 
septicemic general affection in, 739. 
treatment of, 754. 

complications in, 759. 
intubation in, 758. 
local, 757. 
rules for, 762. 
serum therapy in, 755. 
tracheotomy in, 758. 
whooping cough and, 751. 
Diphtherie a streptococque, 741. 
Diphtheritic paralysis, 745. 
Diphtheroid in measles, 645. 
in scarlet fever, 677. 
scarlatinal, treatment of, 725. 
Disease of the placenta in syphilis, 309. 
Diseases, constitutional, 96. 
local, of the new-born, 93. 
of the eye, 85. 
of the umbilicus, 62. 
Distention streaks, 49. 
Dislocation of femur, congenital, 12. 
Dislocations of the upper extremity, due 

to trauma during birth, 61. 
Diverticulum, prolapse of, 69. 
Double limbs, 236. 
Dream actions, 355. 
Dropsy in scarlet fever, 708. 
Drugs causing convulsions, 402. 
Dualistic theory of scrofula and tubercu- 
losis, 285. 
Dubois's disease, 312. 
Dubois's method of tying the cord, 65. 
Ductus Botalli, patulous, 10. 
Dwarfism, rachitic, 257. 
Dysentery in measles, 652. 
Dyspepsia, 167. 
alimentary, 159. 

chronic, of breast-fed children, 177. 
etiology of, 176. 
prognosis of, 177. 
due to oidium albicans, 142. 
Dyspnea, cardiac, in nephritis, 709. 
in heart disease, 9. 
in measles, 638. 
in rhinitis, 459. 

Ear, diphtheria of, 751. 

disease of, from adenoids, 491. 
in scarlet fever, 693. 
Earache in rhinitis, 460. 



SiO 



INDEX OF SUBJECTS 



Eclampsia, 382, 421. 

epilepsy and, differential diagnosis of, 
445. 

haematogenes, 390. 

in hypernutrition, 181. 

reflex, 383. 

sympathetic. 383, 390. 

symptoms of, 421. 

condition of extremities in, 422. 
laryngeal spasm in, 422. 
Ectogenons milk decomposition, 161. 
Ectopia cordis, 8. 

vesica-. 7. 
Eczema, chronic, 95. 

impetiginous, in rhinitis, 459. 

in rickets, 259. 

in scrofula, 291. 

of lip, in adenoids, 490. 
Edematous infiltration, 111. 

diagnosis of, 112. 

pathology of, 111. 

prognosis of, 112. 

prophylaxis of, 112. 

symptoms of, 111. 

treatment of, 112. 
Eggs for infants, 136. 
Elbow-joint in spinal paralysis, 546. 
Electric examination in tetany, 427. 
Enibryonalism, 290. 

Emphysema, cutaneous, from whooping- 
cough, 780. 
Empyema in pneumonia, 599. 
Encephalitis in whooping-cough, 785. 
Encephalocele, 3. 
Encephalopathies, 446. 
Endarteritis, due to syphilis, 319. 

syphilitic, 330. 
Endocarditis, gonorrheal, 88. 

in mumps, 771. 
English disease, 236. 
Enteric fever and broncho-pneumonia, 

602. 
Enteroclysis in intestinal disease, 216. 
Enterospasm, 183. 
Enuresis, 360. 

nocturna, 361. 
in adenoids, 494. 

treatment of, 373. 
Ephemera, 485. 

Epidemic parotitis, 763. See also Mumps. 
Epilepsy, 377. 

adenoids and, 494. 



Epilepsy, due to syphilis, 318. 

eclampsia and, differential diagnosis, 
445. • 

etiology of, 387. 

in rickets, 266. 

prognosis of,i380. 

syphilis and, 379. 

syphilitic, 330. 

treatment of, 380. 
Epispadia, 6, 7.. 
Epistaxis, 474.' 

in constitutional diseases, 475. 

in heart disease, 9. 

in pertussis, 475. 

prognosis of, 476. 

spontaneous, 475? 

symptoms of, 476. 

treatment of, 476. 
Epstein's swinging chair, in rickets, 

284. 
Erb-Duchenne paralysis, 57. 

etiology of, 58. 

prognosis of, 58. 

symptoms of, 58. 

treatment of^ 58. 
Erb's phenomenon in tetany, 427. 
Erb's point, 58, 60. 
Erosions, 193. 
Eruptions from antipyrin, 620. 

from diphtheria antitoxin serum, 620. 

in measles, 631. 
Erysipelas of the new-born, 70. 
Erythema exudativum and measles, 655. 
Erythema infectiosum, rhinitis in, 462. 
Erythema multiforme, 619. 
Erythrocytes, destruction of, in icterus 

neonatorum, 100. 
Eventration, 11. 

Exercise in treatment of speech disturb- 
ances, 345. 
Exophthalmic goiter, 376. 
Extremities, birth trauma of, 50. 

malformations of, 12. 
Eye, affection of, in mumps, 770, 771. 

disease of, 85. 

gonorrheal inflammation of, 85. 

syphilis of, 323. 
Eyelids, injury to, during labor, 48. 
Eyes, disease of, in syphilis, 319. 

pathogenic microorganisms in, 92. 

spasm of, 435. 

tumor of, 436. 



INDEX OF SUBJECTS 



811 



Face, injuries to, during labor, 48. 
Facial nerve, paralysis of, 40. 
Facial paralysis, 38. See also Paralysis, 
Facial. 

due to forceps, 46. 

etiology of, 47. 

in mumps, 768. 

prognosis of, 48. 

symptoms of, 47. 

traumatic, 46. 

treatment of, 48. 
Facial phenomenon in rickets, 262. 

in tetany, 426. 
Facies, change in, from adenoids, 492. 
Family infection in tuberculosis, 304. 
Family predisposition to tuberculosis, 304. 
Fat diarrhea, 181. 

Fatty degeneration, acute, of the new- 
born, 118. 
Febricula, 485. 

Feces, accumulation of, cause of aphasia, 
344. 

character of, in pyloric spasm, 184. 
Feeding, in tuberculosis, 301. 

of children, 122. 
Feedings, number of, for twenty-four 

hours, 125. 
Femur, congenital dislocation of, 12. 
Ferment therapy, 178. 
Fermentation, acid, 162. 

alkaline, 162. 
Fetal myxedema, 241. 
Fetal rickets, 241. 
Fetal syphilis, 309. 
Fettmilch, 132. 
Fetus, blood supply of, 22. 
Fever, convulsions of, treatment of, 451. 

enteric, 163. 

in rickets, 259. 

Pfeiffer's glandular, 479. 

post-scarlatinal, 698. 
treatment of, 727. 
Fingers, contracture of, in spinal paral- 
ysis, 547. 

drum-stick, in heart disease, 9. 

sucking of, 354. 

superfluous, 12. 
First day, food for, 124. 
Fish mouth, in tetany, 426. 
Fissure of lip, in adenoids, 490. 
Fissures, 193. 

treatment of, 194. 



Flat-foot, 551. 

Flora, intestinal, 157. 

Fluid in hydrocephalus, character of, 534. 

Foetus sanguinolentus, 308. 

Folie musculaire, 575. 

Fontanelles, deficient involution of, in 

rickets, 251. 
Food, after sixth month, 134. 

at end of six months, 125. 

for first day, 124. 

for second year, 135. 

for third year, 137. 

ingestion of, in infants, 360. 

volume of, for infants, 134. 
Foot deformity, in spinal paralysis, 550. 
Foot-and-mouth disease, 145. 
Foramen ovale, persistence of, 10. 
Foreign bodies, in the nose, 473. 

introduced by infants into the natural 
cavities, 354. 
Fourth disease, 618. 

etiology of, 619. 

symptoms of, 619. 
Fracture, intra-uterine, 51. 

etiology of, 51. 
Fritsch and Hitzig's cortical experiments, 

393. 
Frontal fontanelle, normal size of, 252. 
Functional neurosis, psychic treatment of, 

369. 
Fungi, umbilical, 68. 
Furunculosis in scrofula, 291. 

Gangrene in pneumonia, 599. 

Garotillo, 731. 

Gartner's fat-milk, 132. 

Gases, interchange of, 22. 

Gastric hypersecretion in pyloric stenosis, 

187. 
Gastric lavage in pyloric stenosis, 190. 
Gastric spasm, 187. 
Gastro-enteritis, 163. 

choleriform, 404. 
Gastro-intestinal autointoxication, 403. 
General spasticity, 558. 
Genitalia, diphtheria of, 751. 

tuberculosis of, 302. 
Genu recurvatum, 549. 
German measles, 612. 
Gland, of the nape of the neck, 480. 

pharyngeal, 480. 

thymus, enlargement of, 37. 



812 



INDEX OF SUBJECTS 



Glands, bronchial, in infantile tuberculo- 
sis, 294. 
tuberculosis of, 295. 
cervical, enlargement of, in rubella. 613. 
disease of, in scrofula, 292. 
in measles, 034. 
mesenteric, tuberculosis of, 302. 
submaxillary, 480. 
submental, 480. 
Glandulae cervicales profunda) laterales, 

480. 
Glandular cervicales profunda) superiores, 

480. 
Glandulae retropharyngealcs, 480. 
Glandular fever, Pfeiffer's, 479. 
Glottis., spasm of, 382, 419. 
craniotabes and, 442. 
due to syphilis, 324. 
etiology of, 421. 
in rickets, 262. 
symptoms of, 420. 
treatment of, 282. 
Gmelin reaction in icterus neonatorum, 97. 
Goiter, exophthalmic, 376. 
Gonorrheal conjunctivitis, 87. 
Gonorrheal inflammation of the eyes, 85. 
Crede's method in, 88. 
diagnosis of, 88. 
etiology of., 85. 
pathology of, 86. 
prognosis of, 88. 
prophylaxis of, 88, 91. 
symptoms of, 85. 
treatment of, 88. 
drugs in, 91. 
silver acetate in, 90. 
silver nitrate in, 89. 
Zweifel's method in, 90. 
Gonorrheal rhinitis, 464. 
Graefe's sign, 376. 
Granulation tuberculosis, 302. 
Graves's disease, 376. 

treatment of, 377. 
Gravitation abscess, differential diagnosis 
of, from retropharyngeal abscess, 
506. 
Gray atrophy in syphilis, 319. 
Gummata in fetal syphilis, 310. 

Habitus, phthisical, 298. 
Hall's hydrocephaloid, 404. 
Hall's, Marshall, method, 33. 



gardening, habit of, 157. 
Harelip, 4. 

pathology of, 4. 
symptoms of, 4. 
treatment of, 5. 
Harrison's furrow, 254. 
Hassel's bodies, 312. 
Hay fever, rhinitis in, 402. 
Head, spasm of, 435. 
Headache, 357. 

from adenoids, 493. 
in Graves's disease, 376. 
in tuberculous meningitis, 519. 
nervous, 358. 
treatment of, 372. 
Head's zones, 364. 
Heart disease, chorea and, 577. 

congenital, cause of convulsions, 406. 

symptoms of, 9. 
in scarlatina, 697. 
Heart malformations, diagnosis of, 10. 
prognosis of, 9. 
treatment of, 10. 
Hebra's salve in intertrigo, 96. 
Helminthiasis, cause of convulsions, 405. 
Hematoma of the muscles, 49. 
Hemicephalus, 1. 
Hemichorea, 574. 
Hemoptysis in heart disease, 9. 
Hemorrhage, due to separation of the cord, 
64. 
intracranial, 44. 
diagnosis of, 45. 
during birth, 41. 
prognosis of, 45. 
symptoms of, 45. 
umbilical, 62. 
Hemorrhagic diathesis in infantile scurvy, 

222. 
Hemorrhoids, treatment of, 194. 
Hereditary neuropathic predisposition, 

343. 
Hereditary syphilis, 308. 

in myotonia, 415. 
Heredity, in scrofula, 287. 

in tuberculosis, 287. 
Hernia, cerebral, 2. 
prognosis of, 3. 
treatment of, 3. 
from whooping cough, 780. 
spinal, 2. 

prognosis of, 3. 



INDEX OF SUBJECTS 



813 



Hernia, spinal, treatment of, 3. 

umbilical, 82. 
Hernia funiculi umbilicalis, 11. 
Herpes in rubella, (114. 
Herpes zoster and measles, 655. 
Hessing's apparatus, in infantile paraly- 
sis, 561. 
Hip-joint, in spinal paralysis, 547. 

paralytic dislocation of, 548. 
Hirschsprung's disease, 192. 

etiology of. 102. 

treatment of, 193. 
Horseshoe kidney. 7. 
Hospitalism, 200. 

Humerus, diaphyseal rupture of, 56. 
prognosis of. 56. 
treatment of, 56. 

epiphyseal separation of, 55. 

fracture of, 53. 
prognosis of. 54. 
symptoms of. 53. 
treatment of, 54. 
Hunger atrophy, 198. 
Hunger cure in atrophy, 210. 
Hunting-dog posture in tuberculous men- 
ingitis, 521. 
Hutchinson's teeth, 269. 
Hutchinson's triad in syphilis, 331. 
Hydrocele, acute, in mumps, 770. 
Hydrocephalocele, 3. 
Hydroeephaloid. 404. 
Hydrocephalus. 1, 530. 

acute, 533. 

congenital. 531. 

associated with syphilis, 318. 

course of, 535. 

etiology of. 531. 

external, 533. 

in rickets, 265. 

meningeal, 533. 

pathogenesis of, 531. 

pathology of, 536. 

prognosis of. 2, 536. 

symptoms of. 534. 

treatment of, 2. 537. 
surgery in, 537. 
Hydronephrosis, 6, 7. 
Hydrotherapy, in convulsions, 451. 

in measles, 667. 
Hyperidrosis universalis in rickets, 262. 
Hyperkinesia, 386. 
Hypernutrition, 181. 



Hypernutrition, danger of. 126. 
diagnosis of, 182. 
etiology of, 181. 
from cow's milk, 131. 
symptoms of, 181. 
treatment of, 182. 
Hypersecretion, gastric, in pyloric steno- 
sis, 188. 
Hypertrophy, congenital pyloric, 187. 
Hypospadia, 6, 7. 
Hysteria, infantile, 350, 362. 
diagnosis of, 366. 
etiology of, 362. 
prognosis of, 375. 
symptoms of, 365. 
treatment of. 367. 
dietetic, 368. 
education in, 370. 
hydrotherapy in, 36S. 
hygienic, 36S. 
suggestion in, 370. 
neurosymptomatic form of, 365. 
Hysterical cough, 490. 
Hysterie naissante, 350. 

Icterus neonatorum, 96. 

destruction of erythrocytes in, 100. 

diagnosis of. 102. 

duration of. 96. 

etiology of. 96. 

feces in. 96. 

origin of. 98. 

pathology of. 97. 

prognosis of. 97. 102. 

symptoms of, 96. 

treatment of, 102. 

urine in, 96. 
Idiocy, adenoids and, 494. 

due to asphyxia, 46. 

due to syphilis, 318. 
Idiopathic vomiting, 187. 
Illusions in chorea, 572. 
Imitation, period of, 340. 
Immunization in diphtheria, 759. 
Impetigo in rickets, 259. 
Increased amount and pressure of the 
cerebrospinal fluid in tetany, 428. 
Tncubation period in syphilis, 313. 
Incubators. 15. 

Infant, calory requirement of. 131. 
Infant foods. 136. 
Infantile cerebral paralysis, 539. 



814 



INDEX OF SUBJECTS 



Infantile essential paralysis, 53!). 
Infantile paralysis, treatment of, subse- 
quent, 5G7. 
Infantile scurvy, 217. 
diagnosis of, 230. 
differential diagnosis of, 231. 
from hysteria, 231. 
from pseudo-paralysis, 231. 
from rickets, 231. 
from syphilis, 231. 
etiology of, 223. 
history of, 217. 
pathology of, 221. 
symptoms of, 218. 
treatment of, 232. 
food in, 233. 
Infantile spinal paralysis, 539. 

infantile cerebral paralysis and, differ- 
ential diagnosis, 559. 
Infants, debilitated, food for, 15. 
prognosis of, 13. 
treatment of, 14. 
general debility of, 13. 
jaundice in, 96. 
normal, weight of, 136. 
Infections, of the oral cavity due to patho- 
genic bacteria, 141. 
of the oral mucous membrane, 138. 
Infectious chorea, 571. 

Infectious diseases, acute, rhinitis in, 461. 
congenital, 16. 
anthrax, 21. 
Asiatic cholera, 21. 
croupous pneumonia, 21. 
enteric fever, 19. 
erysipelas, 21. 
malaria, 21. 
measles, 17, 18. 
relapsing fever, 21. 
scarlatina, 17, 19. 
sepsis, 21. 
tuberculosis, 16. 
variola, 17. 
Infiltration, edematous, 111. 
Influenza, broncho-pneumonia and, 602. 
retropharyngeal abscess and, 506. 
rhinitis in, 457, 461. 
Influenza pneumonia, 596. 
Injury, external, cause of sepsis, 83. 
Intercurrent disease in chorea, 575. 
Intermittent pneumonia, 596. 
Interstitial pneumonia, 599. 



Intertrigo, 95. 
etiology of, 95. 
prophylaxis of, 95. 
treatment of, 95. 
Intestinal canal, length of, 156. 
Intestinal catarrh, chronic, complications 
of, 198. 
symptoms of, 197. 
Intestinal disease, in diphtheria, 747. 
Intestinal disturbances, chronic, of arti- 
ficially fed infants, 196. 
etiology of, 196. 
symptoms of, 196. 
Intestinal ectopia, 69. 
Intestinal infection, treatment of, 171. 

food in, 172. 
Intestinal tuberculosis, 301. 
Intestine, endogenous irritation from, as 

cause of speech defects, 343. 
Intestines, diseases of, in syphilis, 323. 

syphilis of, 324. 
Intracranial hemorrhage during birth, 41. 

labor, 44. 
Intrauterine fracture, 51. 
Intussusception in whooping-cough, 780. 
Invalidism, following whooping-cough, 

779. 
Todococcus buccalis, 139. 
Iodoform in care of the navel, 79. 
Iritis, syphilitic, 323. 
Irritable weakness, 348. 
Itrol in care of navel, 79. 

Jaundice, in infants, 96. 

in scarlet fever, 712. 
Jaw, deformity of, in adenoids, 492. 

lymph supply of, 481. 
Joints, gonorrheal disease of, in the new- 
born, 87. 

tuberculosis of, 302. 
Jumping-jack phenomena in tetany, 428. 

Karvonen's theory in syphilis, 311. 

Kassowitz's law of chronic inflammation 
in rickets, 273. 

Kassowitz's respiratory theory in rickets, 
248. 

Kassowitz's theory of muscular move- 
ments, 395. 

Keller's malt soup, 213. 

Keratitis, parenchymatous, 323. 
due to syphilis, 319. 



INDEX OF SUBJECTS 



815 



Keratitis interstitialis, 331. 
Kernig's sign in meningitis, 511. 
Kidney, aplasia of, G. 

congenital cystic, 0. 

contracted, in syphilis, 330. 

cystic, congenital, 6. 

defects of, 6. 

disease of, in infantile scurvy, 219. 

horseshoe, 7. 

hypoplasia of, 6. 

malformation of, 7. 

syphilitic disease of, 324. 

tuberculosis of, 302. 
Klumpke's paralysis, in syphilis, 318. 
Knee-joint, deformities of, in spinal pa- 
ralysis, 548. 
Kneifernase, 472. 
Koplik's spots in measles, 631. 
Kurella's powder, 195. 
Kyphosis in rickets, 255. 

Labor, premature, due to syphilis, 309. 

Lagophthalmus, 47. 

Lab's method, 34. 

Landry's paralysis in whooping-cough, 

785. 
Laryngeal spasm in eclampsia, 422. 
Laryngitis in scarlet fever, 712. 

treatment of, 665. 
Laryngospasm, 420. 

in rickets, 263. 

tetany and, 429. 
Larynx, disease of, from adenoids, 491. 

stenosis of, in diphtheria, 745. 
in measles, 647. 
Late symptoms of hereditary syphilis, 329. 
Latency, period of, in hereditary syphilis, 

313. 
Lavage, gastric, in pyloric stenosis, 190. 
Lead, cause of convulsions, 402. 
Leichtgehende Brust, 177. 
Leptomeningitis, 508. 
Leptothrix buccalis, 138. 

detection of, 138. 
Leukocytosis, in scarlet fever, 676. 

in whooping-cough,, 785. 
Leukoma, 87. 
Leukoma adherens, 87. 
Lichen in scrofula, 291. 
Liebe's neutral food, 214. 
Liebe's neutral malt extract, 214. 
Liebig's soup, 213. 



Light, insufficient, cause of nystagmus, 

437. 
Limp chorea, 574. 
Lips, lymph supply of, 481. 
Little's disease, 318, 533. 
course of, 556. 
etiology of, 556. 
pathology of, 557. 
prognosis of, 557. 
symptoms of, 554. 
Liver, cirrhosis of, due to syphilis, 320. 
prognosis of, 321. 
treatment of, 321. 
rupture of, during labor, 50. 
syphilis of, 319, 324. 
tuberculosis of, 302. 
Local diseases of the new-born, 93. 
Local examination for adenoids, 495. 
Loffler's bacillus, 753. 

culture methods for, 753. 
Loose foot in spinal paralysis, 551. 
Loose socket in spinal paralysis, 547. 
Lordosis, 544. 
Lorgnette-nose, 472. 
Lues tarda, 329. 
Lumbar puncture, in hydrocephalus, 538. 

in tuberculous meningitis, 528. 
Lungs, atelectases of, in whooping-cough, 
781. 
injury to, during labor, 50. 
Lupus in scrofula, 291. 
Luschka's tonsil, 484. 

anatomy of, 487. 
Luxatio femoris paralytica infrapubica, 

548. 
Lymph glands, enlarged, in scarlet fever, 
690. 
in scarlatina, 613. 
treatment of, 726. 
in scarlet fever, 676. 
swelling of, in syphilis, 323. 
Lymph supply of buccal mucous mem- 
brane, 481. 
of interior nose, 481. 
of lips, 481. 
of tongue, 481. 
Lymphadenitis in diphtheria, 747. 
Lymphadenitis retropharyngeal, acute, 
500. 
prognosis of, 502. 
symptoms of, 501. 
treatment of, 502. 



816 



INDEX OF SUBJECTS 



Lymphatic system, hyperplasia of, in 

measles, 028. 
Lymphatics, cervical, enlargement of, in 
rubella, 013. 
of the neck, acute swelling of, 479. 
Lymphatism, 37. 

Maculae cornea? in rickets, 244. 
Maladie des tics, 353. 
Malformations of extremities, 12. 
Mammary gland, disease of, in mumps, 

770. 
Marasmus, 190. 

Martin's method in care of the navel, 77. 
Mastitis, 94. 

diagnosis of, 94. 

treatment of, 94. 
Mastitis parotidea, 770. 
Masturbation, 355. 

treatment of, 374. 
Mauri ceau maneuver, 48. 
Measles, 024. 

as an epidemic disease, 020. 

broncho-pneumonia and, 001. 

capillary bronchitis in, 048. 

catarrhal stage of, prolonged, 038. 

catastrophes in, 038. 

confluent, 033. 

convulsions in, 053. 

coryza in, 029. 

cough in, 030. 

definition of, 024. 

deviation of, from normal course, 035. 

diagnosis of, 058. 

differential diagnosis of, from drug 
eruptions, 000. 
rotheln, 059. 
scarlatina, 059. 
septic eruptions, 000. 
serum exanthem, 059. 
small-pox, 059. 

diphtheria and, 055. 

eruption of, relapse of, 044. 

etiology of, 024. 
season in, 020. 

fulminant case of, autopsy in, 640. 

fulminant forms of, 039. 

German, 012. See Rubella. 

immunity from, 025. 

lymph-gland enlargement in, 613. 

nodular eruption in, 643. 

pathology of, 627. 



Measles, pemphigus and, 643. 
period of incubation in, 020. 
pneumonic form of, 042. 
prevention of contagion in, 002. 
prognosis of, GG0. 
pseudo-croup in, 038. 
pustule formation in, 043. 
rhinitis in, 402. 
rudimentary eruption in, 059. 
scarlatina and, 055. 
secondary, 027. 
sequel of, treatment of, 008. 
" struck in," 040. 
symptoms of, 028. 
acme of, 033. 
arthritic pains in, 037. 
catarrhal stage in, 028. 
conjunctivitis in, 045. 
defervescence in, 034. 
desquamation in, G35, 044. 
eruptive stage in, 028. 
fever in, 029. 

period of convalescence in, 628. 
prodromal period in, 037. 
renal affection in, 054. 
treatment of, 002. 
aphthae in, 005. 
catarrhal symptoms in, 064. 
derivative method in, 000. 
diet in, 063. 
eyes in, 004. 
hydrotherapy in, 007. 
oral cavity in, 004. 
otitis media in, 664. 
whooping cough and, 656. 
without eruption, 639. 
Meat, overnutrition with, a cause of stut- 
tering, 344. 
Median nerve in spinal paralysis, 547. 
Megastoma enter i cum, 165. 
Melaena neonatorum, 112. 
diagnosis of, 117. 
pathology of, 114. 
prognosis of, 113, 117. 
prophylaxis of, 117. 
symptoms of, 113. 
treatment of, 117. 
Melaena spuria, 117. 
Memory, loss of, in chorea, 572. 
Meningismus, 404. 
Meningitis, 508. 
cerebrospinal, 513. 



INDEX OF SUBJECTS 



817 



Meningitis, cerebrospinal, differential di- 
agnosis of, 514. 
etiology of, 513. 
prognosis of, 514. 
symptoms of, 513. 
treatment of, 514. 
from adenoids, 494. 
partial, 525. 
serous, 510. 

differential diagnosis of, 512. 
pathology of, 510. 
prognosis of, 511. 
symptoms of, 510. 
treatment of, 512. 
simple, 508. 

etiology of, 509. 
syphilitic, 318. 
tuberculous, 299, 514. 
coma in, 524. 
constipation in, 520. 
contractures in, 523. 
convulsions in, 523. 
course of, 518. 
diagnosis of, 299, 526. 
differential diagnosis of, 526. 
from enteric fever, 526. 
from other forms of meningitis 
526. 
etiology of, 515. 
history of, 515. 
pathology of, 517. 
prognosis of, 525. 
symptoms of, 299, 518. 
treatment of, 527. 
Meningocele, 3. 

Meningoencephalitis tuberculosa, 517. 
Mental disease due to trauma during birth, 

45. 
Mental disturbance in mumps, 771. 
Mental faculties, development of, 339. 
Mercury, eruption from, 620. 
Mesenteric glands, tuberculosis of, 302. 
Metabolism, intermediary, of infant, 123. 
Microcephalia, 532. 

Microorganisms, colonization of, in the 
umbilical wound, 70. 
in chorea, 579. 
Micropolyadenia, 314. 
Migraine, 357. 

treatment of, 372. 
Miliaria in measles. 638. 
Miliary tuberculosis, 297. 
53 



Milk, overheating of, as i, cause of in- 
fantile scurvy, 226. 

permanent, 129. 

quantity of, for feeding, 130. 
Milk decomposition, bacterial, 161. 

ectogenous, 161. 
Milk sugar, addition of, to milk, 133. 
Mirror writing in chorea, 573. 
Mixed infection in syphilis, 326. 
Mobius's sign, 376. 
Model baby, 181. 
Moller-Barlow's disease, 132. 
Mollusca pendula, 68. 
Mondamin, 133. 
Mongoloid new-born, 410. 
Monistic theory of scrofula and tuberculo- 
sis, 285. 
Monocercomonas, 165. 
Morbilli, 624. 
Morbilli croup, 656. 
Morbilli elevati, 632. 
Morbilli laeves, 632. 
Morbilli pneumonia, 650. 
Morbillosa sine morbillis, 639. 
Morbus aegyptiacus, 730. 
Morbus syriacus, 731. 
Mother's pride, 181. 
Motor nerves, mechanical hyperirritabil- 

ity of, in tetany, 426. 
Mould fungi, 139. 

Mouth, injury to, during labor, 48. 
Mouth breathing in adenoid vegetations, 

489. 
Mucous membrane, immunization of, 157. 

syphilis of, 313. 
Muguet, 141. 
Multiple osteitis, 217. 
Mumps, 763. 

case history in, 763. 

cause of, 769. 

complications of, 771. 

contagion of, 764. 

diagnosis of, 772. 

duration of attack in, 769. 

epidemics of, 764. 

etiology of, 763. 
age in, 765. 

microorganisms in, 765. 
sex in, 765. 

history of, 763. 

immunity from, 765. 

isolation in, 773. 



818 



INDEX OF SUBJECTS 



Mumps, pathology of, 766. 
period of incubation in, 700. 
prognosis of, 771. 
symptoms of, 76G. 
fever in, 768. 

nervous phenomena in, 771. 
ovary in, 770. 
prodromes in, 766. 
pulse in, 768. 
suppuration in, 769. 
testicle in, 769. 
termination of, 769. 
treatment of, 772. 
bathing in, 773. 
Muscle delirium, 575. 
Muscle frenzy, 575. 

Muscles, injuries to, during labor, 49. 
etiology of, 49. 
prognosis of, 49. 
treatment of, 50. 
Muscular weakness in rickets, 261. 
Mutism, 341. 

physiologic, of new-born, 337. 
Mutitas verminosa, 344. 
Myeloperiostitis, 217. 
Myiasis of the nose, 474. 
Myositis fibrosa, 540. 
Myotonia, 383. 

differential diagnosis of, 416. 
etiology of, 412. 
hypertonia of muscles in, 413. 
of infants, 409. 
pathogenesis of, 411. 
pathologic, of the first grade, 416. 
symptoms of, 410, 413. 
treatment of, 452. 
Myotonia physiologica neonatorum, 415. 
Myotonia spastica perstans, 416. 
Myxedema, fetal, 241. 

Nails, biting of, 354. 
Nasal diphtheria, 747. 
Nasal twang in scrofula, 468. 
Nasopharynx, acute inflammation of, 479. 

adenoid vegetations in, 486. 

artificial infection of, 482. 

diseases of, 478. 

idiopathic inflammation of, 483. 
Navel, care of, 77. 

Ahlfeld's method of, 77. 
Martin's method of, 77. 

diseases of. See Umbilicus. 



Navel, infectious diseases of, 71. 
process of healing of, 00. 
ulcer of, 71. 
Navel bandage, change of, 79. 
Neck, injuries to, during labor, 49. 
rigidity of, in tuberculous meningitis, 
521. 
Necrosis, tuberculous, 303. 
Necrotic pulmonary inflammation in mea- 
sles, 641. 
Nephritis, hemorrhagic, due to syphilis, 
322. 
in infantile scurvy, 220. 
in whooping cough, 782. 
scarlatinal, 700. 
treatment of, 727. 
Nerve, facial, paralysis of, 46. 
Nerves, disease of, in syphilis, 317. 
Nervous diseases, due to trauma during 
birth, 45. 
organic, 375. 
Nervous disease, functional, 347. 
Nervous sphere, hypersensitive, 438. 
Nervous symptoms in hydrocephalus, 535. 
Nervous system, central, defective and 

pathologic development of, 1. 
Nervousness, infantile, 350. 
Neurasthenia, infantile, 350. 
etiology of, 352. 
prognosis of, 375. 
symptoms of, 352. 
treatment of, 367. 
dietetic, 368. 
education in, 370. 
hydrotherapy in, 368. 
hygienic, 368. 
Neuritis, multiple, in mumps, 771. 

toxic, in diphtheria, 747. 
Neurohysteria, 351. 
Neurosis, functional, 435. 
New-born, diseases of, 1. 

defective and pathologic development 
in, 1. 
Nicoladoni's operation in infantile paral- 
ysis, 563. 
Night terrors, 353. 

treatment of, 373. ' 
Nodding spasm, 349. 
Noma, 149, 653. 

treatment of, 665. 
Nose, bleeding from, 474. 
diseases of, 456. 



INDEX OF SUBJECTS 



819 



Nose, disturbance of growth of, in ade- 
noids, 492. 
foreign bodies in, 473. 
symptoms of, 473. 
treatment of, 474. 
interior of, lymph supply of, 481. 
scrofula of, 467. 
pathology of, 467. 
prognosis of, 468. 
treatment of, 468. 
syphilis of, 469. 
deformities in, 472. 
prognosis of, 470. 
symptoms of, 469. 
treatment of, 470. 
Nursing, difficult, in heart disease, 9. 
Nurslings, syphilis of, 313. 
Nystagmus, 435. 
in rickets, 265. 
symptoms of, 436. 

Obstetric hand in tetany, 423. 

Occipital bone, injuries to, 43. 

Ocular changes in tuberculous meningitis, 

522. 
Ocular symptoms, in adenoids, 494. 

meningitis, 300. 
Odor, of the poor, 248. 

putrid, in stomatitis, 140. 
Oidium albicans, 141. 

complicating Bednar's, aphthse, 148. 
Olympic brow in rickets, 253. 
Omphalitis, 71. 
Omphalorrhagia, 65. 

symptoms of, 65. 

treatment of, 66. 
Omphalosite, 8. 
Onanism, 355. 

treatment of, 374. 
Ophthalmia, scrofulous, in measles, 645. 
Ophthalmoblennorrhea, 87. 
Opium, cause of convulsions, 402. 
Optic neuritis in tuberculous meningitis, 

523. 
Oral cavity, gonorrheal disease of, in the 

new-born, 87. 
Oral mucous membrane, infections of, 138. 
Orchitis in mumps, 769. 
Orchitis parotidea, 769. 
Organic nervous affections, 375. 
Organs, abdominal, injury to, during la- 
bor, 50. 



Organs, internal, syphilis of, 316. 
Osteitis, multiple, 217. 
Osteochondritis, 310. 
Osteogenesis imperfecta, 241. 
Osteomalacic form of rickets, 272. 
Osteoporosis congenita, 241. 
Osteosclerosis, 303. 
Otitis in scrofula, 291. 
Otitis media, gonorrheal, 87. 

in diphtheria, 747. 

in measles, 646. 

in rhinitis, 460. 

in scarlet fever, 693. 

scarlatinal, symptoms of, 694. 

in whooping cough, 786. 
Ovarialgia, 364. 

Ovary, disease of, in mumps, 770. 
Overfeeding, 181. 
Oxyuris vermicularis as cause of aphasia, 

344. 
Ozena, 468, 470. 

etiology of, 470. 

pathology of, 471. 

Pachymeningitis, 508. 

Pagenstecher's eye-salve, 664. 

Palate, cleft, 4. 

Palatochisis, 4. 

Pancreatitis in mumps, 771. 

Pankreon in chronic dyspepsia, 178. 

Panophthalmia, 87. 

in measles, 645. 
Paralysis, diphtheritic, 745. 

due to pressure, 50. 

facial, in mumps, 768. 

flaccid, in syphilis, 317. 

general, in meningitis, 301. 

in chorea, 574. 

infantile cerebral, 539. 
from syphilis, 318. 

infantile spinal, 539. 

in tuberculous meningitis, 524. 

of arm during birth, 57. 

post-diphtheritic, 746. 

progressive, 330. 

spinal, contractures in, 540. 
Paralytic dislocation, symptoms of, 548. 
Parasites in nose, 473. 
Parasyphilitic symptoms, 324. 
Parotitis, epidemic, 763. 

metastatic, 772. 
Parrot's pseudo-paralysis, 231, 317. 



820 



INDEX OF SUBJECTS 



Pasteurization of milk, 130. 

in infantile scurvy, 224. 
Pathologic development of the new-born, 1. 
Pavor nocturnus, 353. 
Pectus carinatum, 254. 
Pedatrophia, 196. 
Pegnin in chronic digestive disturbances 

of infancy, 178. 
Pelvic girdle, displacement of, in rickets, 

255. 
Pemphigus, cachecticus, 104. 
foliaceus, 104, 108. 
malignant, 104. 
measles and, 643. 
neonatorum, 103. 
bacteriology of, 105. 
complications of, 104. 
differential diagnosis of, 106. 
etiology of, 104. 
pathology of, 103. 
prognosis of, 107. 
prophylaxis of, 107. 
symptoms of, 103. 
treatment of, 107. 
syphiliticus, 106, 312. 
prognosis of, 312. 
Penghawar Djambi in epistaxis, 477. 
Peri-arteritis, 72. 
Peribronchitis caseosa, 297. 
Perimastitis, 94. 
Periostitis, hemorrhagic, 217. 
of the new-born, 72. 
syphilitic, 330. 
Peripulmonary groove, 34. 
Peripylephlebitis due to syphilis, 321. 
Peritoneal tuberculosis, 302. 
Peritoneum, changes of, in syphilis, 323. 
Peritonitis, 72. 

due to syphilis, 321. 
in scarlet fever, 692. 
Permanent milk, 129. 
Persistent spasms, 409. 
Pertussis, 774. See Whooping Cough. 

broncho-pneumonia and, 602. 
Pes equinus, 551. 
Petit mal, 379. 

Peyer's patches in scarlet fever, 677. 
Pfeiffer's glandular fever, 479. 
complications of, 485. 
etiology of, 485. 
symptoms of, 483. 
Phalangitis, 316. 



Pharyngeal gland, 480. 
Pharyngeal stenosis, 462. 
Pharyngeal tonsil, 479. 
Pharyngitis, acute catarrhal, 500. 

phlegmonous, 500. 
Pharyngitis granulosa, 490, 500. 
Pharynx, diseases of, 456, 500. 
Phobias, 352. 
Photophobia, in scrofula, 291. 

in tuberculous meningitis, 521. 
Phthisical habitus, 298. 
Physiognomy in scrofula, 291. 
Physiologic dyspepsia, 169. 
Physiology, in digestive diseases, 154. 

of muscular movements, 395. 
Pieds bots tendineux-osseux, 551. 
Pilocarpin in measles, 666. 
Pinceneznose, 472. 
Placenta, cause of septic infection, 84. 

disease of, 309. 

tuberculosis from, 85. 
Placental circulation, 22, 23. 
Placques, mucous, 316. 

muqueuses, 323. 
Pleurisy in pneumonia, 598. 
Pneumonia, 72, 589. 

abortive, 597. 

alba, 65. 

caseous, 297. 

symptoms of, 297. 

cerebrate, 592. 

complications of, 598. 

convulsions in, 592. 

course of, 594. 

croupous, 599. 

intermittent, 596. 

interstitial, 312, 599. 

lobar, 591. 

lobular, 591. 

migrans, 596. 

pathology of, 590. 

periglandular tuberculous, 297. 

primary, symptoms of, 592. 
treatment of, 605. 
hydrotherapy in, 606. 

prognosis of, 598. 

prophylaxis of, 604. 

white, 311. 
Pneumonic form of measles, 642. 
Pneumonie lobulaire generalisee, 591. 
Poison glands in scrofula, 292. 
Pollakiuria, 361. 



INDEX OF SUBJECTS 



cS21 



Polymortality in syphilis, 312, 324. 
Polyneuritis in whooping-cough, 785. 
Post-measles pneumonia, (550. 
Pregnant syphilitic woman, treatment of. 

335. 
Premature infants, muscles of, 411. 

predisposed to hemorrhage, 63. 
Pressure marks, 38. 

treatment of, 38. 
Pressure streaks, 38. 
Pressure ulcers, 61. 

Primary plastic iritis due to syphilis, 319. 
Prodromes, in meningitis, 520. 
Profeta's law, 335. 
Projection of fetal syphilis, 316. 
Prostatitis in mumps, 770. 
Pseudo-croup, 359. 

in adenoids, 491. 

in measles, 638. 

prophylaxis of, 372. 
Pseudo-paraplegia in rickets, 261. 
Pseudo-tetanus, 416. 
Psoriasis palmaris, 316. 
Psoriasis plantaris, 316. 
Psychical irritation, spasm in, 439. 
Psychoses, in chorea, 575. 

in whooping cough, 783. 
Puerperal scarlatina, 675, 715. 
Pug-nose, 471. 

Pulmonary edema in nephritis, 710. 
Pulmonary inflammation, necrotic, due to 

measles, 641. 
Pulmonary stenosis, congenital, 8. 
Pulmonary tuberculosis, 296. 
Pulse, in tuberculous meningitis, 519. 

slow, in meningitis, 521. 
Putrefactive bacteria in oral cavity, 148. 
Pyemia, in scarlet fever, 678. 

of the navel, 71. 

of the new-born, 73. 
symptoms of, 75, 76. 
Pyloric hypertrophy, congenital, 187. 
Pyloric spasm, simple, 183. 

symptoms of, 184. 
Pyloric stenosis, 183. 

etiology of, 183. 

genuine, 183. 

pathogenesis of, 186. 

prognosis of, 186. 

treatment of, 188. 

artificial nourishment in, 189. 
drugs in. 190. 



Pyloric stenosis, treatment of, surgical, 188. 
Pylorus, constriction of, 183. 

spasm of, 183. 
Pyocyaneus diarrhea, 163. 
Pyodermia, 401. 

Quinin. eruption from, 620. 
in whooping cough, 788. 

Rachitis, 236. See Rickets. 

Rachitis tarda, 244, 258. 

Rachitisme, 236. 

Radioscopy in rickets, 269. 

Raie blanche, 682. 

Recent diffuse hepatitis complicating 

syphilis, 319. 
Rectum, fissure of, 405. 

prolapse of, from whooping cough, 780. 
Relapse in pneumonia, 600. 
Relation of scrofulosis to tuberculosis, 285. 
Reprise in whooping-cough, 778. 
Resistant vascular stump, 67. 
Respiration, normal, cause of, 22. 
Respiratory tract, defects of, 7. 

septic infection from, 84. 
Retropharyngeal abscess, 502. 
diagnosis of, 504. 
etiology of, 506. 
symptoms of, 503. 
treatment of, 504. 
Rheumatic affections in measles, 654. 
Rheumatism, acute articular, and chorea. 
582. 
scarlatinal, 695. 
duration of. 696. 
endocarditis in, 696. 
symptoms of, 696. 
treatment of, 727. 
Rhinitis, acute, 457. 

bacteriology of, 457. 
complications of, 460. 
etiology of, 457. 
symptoms of, 458. 
treatment of, 465. 
chronica atrophicans, 470. 
diphtheritica, 464. 
fibrinosa, 464. 
gonorrheal, 464. 
hyperplastica, 469. 
hypertrophica, 490. 
in acute infectious diseases, 461.. 
psuedo-membranacea, 462, 748. 



822 



INDEX OF SUBJECTS 



Rhinitis, syphilitic, 312. 
Rhinoscopy in adenoids, 495. 
Ribke's infant powder, 195. 
Rickets, 236. 

acquired, symptoms of, 250. 

acute, 217, 209. 

age of greatest frequency of, 243. 

of onset in, 241. 
cataleptic phenomena in, 437. 
congenital, 241. 

anatomical researches in, 242. 
symptoms of., 250. 
coxa vara in, 257. 
differential diagnosis of, 268. 
from hereditary syphilis, 268. 
infantile myxedema, 268. 
infantile scurvy, 269. 
osteomalacia, 269. 
poliomyelitis, 269. 
spondylitis, 269. 
distribution of, 238. 
etiology of, 240, 245. 

acid intoxication in, 246. 
deficiency of lime in, 246. 
digestive disturbances in, 247. 
disturbance of an organ with inter- 
nal secretion in, 249. 
excess of potassium salts in, 247. 
infections in, 248. 
Kassowitz's theory in, 248. 
nutritive hypothesis in, 245. 
unsanitary habitations in, 248. 
fetal, 241. 
florid, 244. 
frequency of, 239. 
heredity in. 244. 
history of, 236. 

hyperirritability spasms and, 441. 
immunity from, 238. 
influence of season in, 240. 
inherited, 244. 

intra-uterine development of, 243. 
maculae cornea? in, 244. 
pathology of, 271. 

bones, changes in, 272. 
stage of acme, 271. 
stage of cure, 271. 
stage of onset, 271. 
percentage of infants born with, 242. 
prognosis of, 270. 
prophylaxis of, 275. 
racial peculiarities of, 238. 



Rickets, relation of, to nervous affections, 
262. 
relation to other diseases, 267. 

epilepsy, 268. 

infantile scurvy, 267. 

malaria, 267. 

syphilis, 267. 

tuberculosis, 267. 
respiratory theory in, 240. 
stage of onset of, 242. 
symptoms of, 250. 

cardiac hypertrophy in, 260. 

changes in lower extremity in, 256. 

changes in thorax in, 254. 

changes in upper extremity in, 256. 

chicken breast in, 254. 

craniotabes in, 251. 

cranium natiforme in, 268. 

curvature of legs in, 257. 

deficient involution of fontanelles in, 
251. 

displacement of pelvic girdle in, 255. 

distention of abdomen in, 259. 

disturbance in growth of facial bones 
in, 253. 

epilepsy in, 266. 

fever in, 259. 

flat-foot in, 257. 

general nutrition in, 259. 

Harrison's furrow in, 254. 

hydrocephalus in, 265. 

kyphosis in, 255. 

nervous affections in, 262. 

nystagmus in, 265. 

Olympic brow in, 253. 

pain in, 255. 

pectus carinatum in, 254. 

pulmonary affections in, 260. 

rosary in, 254. 

scoliosis in, 255. 

softness of sutures in, 251. 

status thyricus in, 259. 

teeth in, 253. 
treatment of, 275. 

cod-liver oil in, 280. 

drugs in, 278. 

food in, 276. 

iron in, 283. 

mountain climate in, 277. 

organo-therapeutics in, 284. 

orthopedic apparatus in, 284. 

phosphorus in, 279. 



INDEX OF SUBJECTS 



823 



Rickets, treatment of, salt baths in, 278. 

sea baths in, 277. 
Rigidity of neck in meningitis, 521. 
Rosary, rachitic, 254. 
Roseola estiva, 619. 
Rotheln, 012. 

rhinitis in, 462. 
Rubella, 612. 

clinical history of, 612. 

desquamation in, 617. 

diagnosis of, 614, 620. 

differential diagnosis of, 621. 

eruption in, 615. 

rhinitis in, 462. 

sequels of, 614. 

symptoms of, 613. 

treatment of, 622. 

urine in, 617. 
Rubeola, 624. 

Rupture, congenital, of umbilical cord, 
11. 

Saddle-nose, 314, 472. 
St. Vitus's dance, 570. 
Salaam spasm, 435. 
Salivation in adenoids, 494. 
Sanoform in care of the navel, 79. 
Santonin, cause of convulsions, 402. 
Saprophytic microbes in the mouth, 138. 
Scaphoid belly in tuberculous meningitis, 

520. 
Scarlatina, 670. 

broncho-pneumonia and, 602. 

fulminans, 686. 

gravissima, 686. 

maligna, 686. 

miliaris, 682. 

puerperal, 715. 

retropharyngeal abscess and, 506. 

rhinitis in, 462. 
Scarlatinal diphtheroid, 688. 
Scarlatinal nephritis, 700. 

pulmonary edema in, 710. 

symptoms of, 705. 
heart in, 709. 
urine in, 705. 
Scarlatinal rheumatism, 695. 
Scarlatinal typhoid, 698. 
Scarlatinoid exanthem, 715. 
Scarlet fever, 670. 

bacteriology of, 672. 

coagulation necrosis in, 677. 



Scarlet fever, convulsions in, 680. 
definition of, 670. 
diagnosis of, 715. 
differential diagnosis of, 715. 

from drug eruptions, 715. 

serum eruptions, 716. 
diphtheria and, 713. 
epidemics of, 672. 
etiology of, 671. 
history of, 670. 
mild cases of, 685. 
morbidity of, 671. 
pathology of, 676. 

heart in, 676. 

kidney in, 702. 

lymph glands in, 676. 

pharynx in, 676. 

skin in, 679. 
period of incubation of, 675. 
prognosis of, 717. 
prophylaxis of, 719. 
relapse in, 699. 
rudimentary cases of, 685. 
symptoms of, 679. 

appendicitis in, 692. 

bronchitis in, 712. 

chin in, pallor of, 680. 

diarrhea in, 713. 

disease of ear in, 693. 

dropsy in, 708. 

eruption of, 681. 

fever in, 682. 

heart in, 696. 

jaundice in, 712. 

joints in, 693. 

kidney in, 700. 

laryngitis in, 712. 

late fever in, 698. 

mouth in, examination of, 680. 

nervous phenomena in, 713. 

prodromes in, 680. 

pulse in, 683. 

purpura in, 715. 

tongue in, 680. 

uremia in, 707. 

vomiting in, 680. 
transmission of, 719. 

manner of, 674. 
treatment of, 719. 

alcohol in, 724. 

caffein in, 730. 

diet in, 721. 



824 



L\DEX OF SUBJECTS 



Scai let fever, treatment of, digitalis in, 
730. 
disinfection in. 710. 
general, 722. 
hydrotherapy in. 723. 
ice in. 72(i. 

Btreptococcus serum in. 72.S. 
strychnin in, 730. 
vaiiations of, from the common type, 

685. 
varicella and, 714. 
Schroder-Mtinzer criterion, 208. 
Schroeder's method, 34. 
Schulze's method, 30. 
accidents from, 31. 
" Schwergehende Brust," 177. 
Sclerema. 14. 
Sclerema adiposum, 111. 
Sclerema edematosum, 111. 
Sclerema neonatorum, 109. 
diagnosis of. 110. 
differential diagnosis of, 110. 
etiology of, 110. 
pathology of, 109. 
prognosis of, 110. 
prophylaxis of, 110. 
symptoms of, 109. 
treatment of, 110. 
Sclerosis, multiple, in whooping-cough, 

785. 
Scoliosis, in rickets, 255. 

paralytic, 544. 
Scorbut infantile, 217. 
Scrofula, adenoids and, 494. 
local phenomena in, 290. 
measles and, 657. 
mucous membranes in, 291. 
of the nose, 467. 
Scrofuloderma, 291. 
Scrofulosis, 285, 290. 
disease of bones in, 292. 

joints in, 292. 
erethistic, 290. 
prognosis of, 293. 
torpid. 290. 
treatment of, 306. 
Scurvy, infantile. See Infantile Scurvy. 

convulsions in, 220. 
Seborrhea, in rickets, 259. 

in syphilis, 315. 
Secondary hemorrhage of the umbilical 
cord. 63. 



Secondary measles, 627. 

Seeligmuller's antagonistic - mechanical 

theory of muscle action. 542. 
Sepsis, in syphilis, 327. 

of the navel, 71. 
Septic infection, from digestive tract. 83. 

from external injury, 83. 

from respiratory tract, 84. 

sources of, in the new-born, 83. 
Septicemia of the new-born, 73. 

prognosis of, 75. 

symptoms of, 75. 

treatment of, 76. 
Septicopyemia of the new-born, 73. 
Septum ventriculorum, defects of. 10. 
Sequels of rubella, 614. 
Serum exanthem resembling measles. 659. 
Sheaths, medullary, of conduction tracts, 

in convulsions, 385. 
Shoulder, paralysis of, 545. 
Shoulder-blades, retraction of, in spinal 

paralysis, 546. 
Shoulder-girdle, injuries to, 57. 
Sign, Chvostek's, 262, 426. 

Mobius's, 376. 
Silver catarrh. 90. 
Simonart's bands, 38. 
Sinus, rupture of, 44. 
Skin, blueness of, in congenital heart dis- 
ease. 9. 

contusions of, 38. 

eruptions of, in infantile syphilis, 314. 

syphilis of, 313. 

tuberculosis of, 302. 
Skull, injuries to, during birth, 42. 
Sleep, disturbance of, in adenoids, 494. 

in neurasthenia, 353. 
Slow pulse in tuberculous meningitis, 521. 
Snuffling, 469. 

in syphilis, 313. 
Soft chorea, 574. 
Soor, 141. 

Soxhlet apparatus in infantile scurvy. 224. 
Spasm, gastric, 187. 
congenital, 187. 

hyperirritability, etiology of, 437. 
rickets and, 441. 

nodding, 349. 

of glottis, 382. 

respiratory, 419. 

simple clonic, 400. 
symptoms of, 400. 



INDEX OF SUBJECTS 



825 



Spasmophilia, 385. 

physiologic, 416. 
Spasmus nictitans, 348. 
Spasmus nutans, 349, 435. 

in rickets, 262. 

symptoms of, 435. 
Spastic contractures in cerebral paralysis, 

553. 
Spastic rigidity, congenital, 553. 
Spastic spinal paralysis in whooping- 
cough, 785. 
Spectacle-nose, 472. 

Speech, alteration of, from adenoids, 
492. 

development of, 337. 

in hydrocephalus, 535. 

reflex, period of, 339. 
Speech disturbances of childhood, 337. 

diet in, 345. 

due to endogenous irritation from in- 
testine, 343. 
constipation, 343. 

exercise treatment of, 345. 

from improper feeding, 344. 

natural prophylaxis of, 340. 
Spina bifida, symptoms of, 2. 
Spinal cord, membranes of, in tuberculous 

meningitis, 525. 
Spinal paralysis, infantile, 539. 

pathology of, 539. 

prognosis of, 560. 

symptoms of, 540. 

treatment of, 560. 
Spine, curvature of, 544. 
Spleen, enlargement of, in rubella, 613. 
in syphilis, 314, 323. 

rupture of, during labor, 50. 

syphilis of, 324. 

tuberculosis of, 302. 
Spongiosa, gumma of, 323. 
Sputum coctum, 779. 
Squamous suture, rupture of, 43. 
Stammering, 342. 

physiologic, 343. 
Staphylococci, oral infection by, 144. 
prognosis of, 145. 
symptoms of, 144. 
Staphylococcus enteritis, 163. 
Staphyloma, 87. 
Status dyspepticus, 167. 
Status epilepticus, 380. 
Status lymphaticus, 444. 



Status thymicus, 444. 

in rickets, 259. 
Stellwag's sign, 376. 
Stenosis, congenital aortic, 8. 
of pulmonary artery, 8. 
of pylorus, 183. 
Sterilization of milk, 128. 
in infantile scurvy, 224. 
Stomach, affections of, in syphilis, 323. 

aphasia from overloading of, 344. 
Stomatitis, aphthosa, 145. 
course of, 146. 
prognosis of, 146. 
symptoms of, 145. 
treatment of, 151. 
catarrhal, 139. 

symptoms of, 139. 
due to pathogenic bacteria, 141. 

symptoms of, 142. 
gonorrhoica, 143. 
prophylaxis of, 149. 
treatment of, 149. 
ulcerosa, 148. 

diagnosis of, 149. 
etiology of, 148. 
prognosis of, 149. 
symptoms of, 148. 
treatment of, 152. 
Strawberry tongue in scarlet fever, 684. 
Streaks, distention, 49. 
Streptococci, in scarlet fever, 672, 678. 
oral infection by, 144, 145. 
symptoms of, 144. 
Streptococcus enteritis, 163. 
Streptococcus sepsis in scarlet fever, 678. 
Stridor congenitus, 444. 
Strypsjuka, 731. 
Stump, resistant vascular, 67. 
Stuttering, 342, 361. 

due to overnutrition with meat, 344. 
etiology of, 343. 
from adenoids, 493. 
physiologic, 343. 
Subdural hemorrhage during birth, 41. 
Submaxillary glands, 480. 
Submental glands, 480. 
Substitutes for breast milk, 128. 
Suffocation, cause of, in fetus, 23. 
Suffocative catarrh in measles, 649. 
Suspended animation. 24. 
Suture, squamous, rupture of, 43. 
Sutures, softness of, in rickets, 251. 



826 



INDEX OF SUBJECTS 



Sweating, 359. 

in infantile scurvy. 220. 
Sydenham's chorea, 571. 
Sylvester's method, 33. 
Syndactylia, 12. 

Synovitis, purulent, in syphilis, 327. 
Syphilis, abortion in, 308. 

complicated with jaundice, 322. 
condylomatous, 323. 
fetal, 309. 

changes in the organs in, 309. 
hemorrhagic, 327. 
hereditaria tarda, 329, 470. 
hereditary, 308. 

anatomical lesions of, 310. 
diagnosis of, 327. 
differential diagnosis of, 328. 
prognosis of, 328. 
relapses in, 329. 
prophylaxis of, 331. 
relapse in, 323. 
transmission of, 308. 
treatment of, 331. 
nourishment in, 334. 
influence of, upon hemorrhage, 65. 
of bones, 316. 

central nervous system, 318. 
eye, 323. 

internal organs, 316. 
liver, 319. 

mucous membranes, 313. 
nose, 469. 
nurslings, 313. 
skin, 313. 
pulmonary, 322. 
Syphilomata, in syphilitic meningitis, 319. 
miliary, 310, 311. 

Tabes, infantile, 330. 

mesenterica, 196, 302. 
Tache cerebrale, 522. 
Tache meningitique, 522. 
Talipes calcaneous, 551. 
Talipes cavus, 551. 

Tartar emetic in broncho-pneumonia, 607. 
Teeth, deformity of, in syphilis, 331. 

disease of, in infantile scurvy, 219. 

disturbance of, in rickets, 253. 

gritting of, 354. 

rupture of, cause of convulsions, 406. 
Telescope-nose, 472. 
Temperature, effect of, on milk, 160. 



Tendinoplasty in infantile paralysis, 560. 
Tendon reflex in Little's disease, 550. 
Tertiarisme d"embl6e, 330. 
Testicle, atrophy of, from mumps, 770. 

disease of, in mumps, 769. 
Testicles, syphilitic disease of, 323. 
Tetania infantilis, 431. 
Tetanoid condition, 417, 434. 

of the new-born, 70. 
Tetanus apnoicus infantum, 425. 
Tetanus neonatorum, 82, 414. 
Tetanus uteri, 24. 
Tetany, 382, 383. 

etiology of, season in, 434. 
frequency of, 433. 
in hypernutrition, 181. 
in rickets, 262. 
infantile, 423. 

symptoms of, 423. 
laryngospasm and, 429. 
latent, 423, 431. 

symptoms of, 431. 
manifest, 423. 

symptoms of, Chvostek's sign in, 424. 
consciousness in, 424. 
electric examination in, 427. 
Erb's phenomenon in, 427. 
facial phenomenon in, 426. 
fish mouth in, 426. 
increased amount and pressure of the 

cerebrospinal fluid in, 428. 
jumping-jack phenomenon in, 428. 
mechanical hyperirritability of the 

motor nerves in, 426. 
Thiemich-Mann's sign in, 425. 
Trousseau's phenomenon in, 423. 
Thiemich-Mann reaction in tetany, 428. 
Thiemich-Mann's symptom in tetany, 425. 
Thoracic cavity, incomplete closure of, 7. 
Thorax, deformity of, from adenoids, 492. 
Thrush, 141. 

diagnosis of, 143. 
metastasis in, 142. 
prognosis of, 143. 
symptoms of, 142. 
Thymus gland, enlargement of, 37. 
function of, 444. 
hyperplasia of, 444. 
Thyroid gland, relation of, to convulsions, 

445. 
Toes, superfluous, 12. 
Tongue, lymph supply of, 481. 



INDEX OF SUBJECTS 



827 



Tonsil, pharyngeal, anatomy of, 487. 

congenital enlargement of, 488. 
Tonsillar ring. W'aldeyers, 479. 
Tonsillitis, relapsing, 490. 
Tonsils, hypertrophy of, in scrofula, 291. 
Tophi of the cranium, syphilitic, 323. 
Torticollis paralytica. 543. 
Toxic symptoms in syphilis, 324. 
Tract, digestive, malformations of, 4. 

respiratory, defects of, 7. 
Transplantation of tendons in infantile 

paralysis, 563. 
Trauma, during birth, 37. 
causes of, 38. 
in functional neurosis, 369. 

tuberculosis, 297, 303. 
meningitis and, 509. 
retropharyngeal abscess and, 506. 
Tricuspid valve, disease of, 10. 
Trismus, 82. 
Trophic disturbances in spinal paralysis, 

540. 
Trousseau's phenomenon, 423. 

in rickets, 262. 
Tuberculosis, 293. 
adenoids and, 494. 
broncho-pneumonia and, 601, 602. 
family infection in, 304. 
family predisposition in, 304. 
from the placenta, 85. 
in congenital heart disease, 10. 

whooping cough, 781. 
infantile, 285, 294. 

symptoms of, 294. 
infiltrated, 303. 
intestinal, 301. 

symptoms of, 301. 
measles and, 657. 
miliary, 297. 

symptoms of, 297. 
of bones, 302. 

bronchial glands, symptoms of, 295. 
genitalia, 302. 
joints, 302. 
kidneys, 302. 
liver, 302. 

mesenteric glands, 302. 
peritoneum, 302. 
skin, 302. 
spleen, 302. 
primary cutaneous, 291. 
prophylaxis of, 304. 



Tuberculosis, pulmonary, 296. 

symptoms of, 296. 
transmission of, 29. 

by placenta, 16. 
treatment of, 304. 

diet in, 305. 

drugs in, 306. 

serum in, 307. 

specifics in, 306. 

tuberculin in, 307. 
Tuberculous infarct, 303. 
Tuberculous meningitis, 514. 
Tumor albus, 657. 
Tussis-convulsiva, 774. 
Twins, care of the cord in, 81. 
Typhoid, scarlatinal, 698. 

treatment of, 727. 
Tyrotoxicon, 161. 

Ueberrum plung, 371. 

Ulcer, sublingual, in whooping-cough, 779. 

Ulcers from pressure, 61. 

Ulnar nerve in spinal paralysis, 547. 

Umbilical adenomata, 68. 

Umbilical cord, care of, in twins, 81. 

circulation of, 66. 

congenital rupture of, 11. 

infection of, diagnosis of, 74. 

ligature of, 62. 

rupture of, treatment of, 11. 

septic inflammation of, 73. 
Umbilical fungi, 68. 

treatment of, 68. 
Umbilical hemorrhage, 62. 

etiology of, 63. 

treatment of, 64. 
Umbilical hernia, 82. , 

treatment of, 12. 
Umbilical wound infection, accidental, 76. 
Umbilicus, diseases of, 62. 

granulation proliferation of, 68. 

putrefactive destruction of, 71. 

pyemia of, 71. 

sepsis of, 71. 
Uremia, in diphtheria, 744. 

in scarlet fever, 707. 

Uremic convulsions, 403. 

Ureter, malformations of, 6. 

prognosis of, 7. 

treatment of, 7. 

obstruction of, 6. 
Urethritis in mumps, 770. 



828 



INDEX OF SUBJECTS 



Urinary apparatus, malformations of, G. 
Urine, evacuation of, 360. 
in icterus neonatorum, 96. 
measles, 634. 
syphilis, 322. 
involuntary evacuation of, 3G6. 
Urticaria in measles, 638. 
Urticaria-like eruption in scarlet fever, 
682. 

Vaccinia and measles, 654. . 
Valvular defects, individual, 10. 
Varicella, measles and, 654. 

rhinitis in, 464. 

scarlatina and, 714. 
Vasomotor symptoms in tuberculous men- 
ingitis, 522. 
Veit-Smellie maneuver, 48. 
Venesection in convulsions, 451. 

in nephritis, 729. 
Vertebral column, curvature of, from ade- 
noids, 492. 

trauma to, 50. 
Vertigo, 357. 
Viennese potion, 195. 
Vitality, defective, in syphilis, 312. 
Vitia cordis, congenital, 8. 
Vocal cords, membrane formation upon, 

in measles, 648. 
Vomiting, cerebral, 300. 

congenital, 187. 

from adenoids, 494. 

hysterical, 366. 

in pyloric spasm, 184. 

tuberculous meningitis, 520. 
Vulvovaginitis. 94. 

diagnosis of, 94. 

in mumps, 770. 

treatment of, 94. 

Waldeyer's lymphatic ring, 480. 

Waldeyer's tonsillar ring, 479. 

Wandering pneumonia, 596. 

Weaning, 126. 

Weaning diarrhea, 165. 

Web formation. 12. 

Wegner's osteochondritis, 310. 

Weighing, necessity for, in children, 179. 

Weight of normal infants, 136. 



Welander'8 sack method in syphilis, :;:.. 

Wharton's jelly, 63, 72. 
\\ hooping-cough, 774. 
clinical picture of, 774. 
complications of, 780, 
convulsions in, 781. 
course of, 778. 
diagnosis of, 786. 
differential diagnosis of, 787. 
etiology of, 775. 
age in, 776. 
contagium of, 775. 
microorganisms in, 776. 
season in, 776. 
mixed infections in, 785. 
pathogenesis of, 775. 
prognosis of, 786. 
prophylaxis of, 787. 
rickets and, 780. 
sequels of, 780. 
symptoms of, 778. 

attack in, character of, 778. 
catarrhal stage in, 778. 
convulsive stage in, 779. 
cutaneous emphysema in, 780. 
heart affections in, 782. 
hemorrhage in, 780. 
hernia in, 780. 
intussusception in, 780. 
laryngospastic attacks in, 780. 
leukocytosis in, 785. 
primary stage in, 778. 
prolapse of rectum in, 780. 
psychoses in, 783. 
respiratory spasm in, 779. 
second catarrhal stage in, 779. 
sublingual ulcer in, 779. 
whoop in, production of, 778. 
treatment of, 787. 
Winckel's disease, 65, 120. 
pathology of, 120. 
prognosis of, 120. 
symptoms of, 120. 
'treatment of, 120. 
Witch's milk, 94. 
Worms, cause of convulsions, 404. 
Writing in chorea, 573. . 
Writing position in tetany, 424. 
Wry-neck, paralytic, 543. 



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